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QUICK SELLING GUIDEWEALTHSure LIFETM

Interest Sensitive Single Premium Whole Life Insurance

Client Information Name

Email

Street Address

Phone

Agent Information Name

Email

Phone

• Pre-Qualification: Review list of impairments in the WealthSure Life Agent Guide with your client. If the client acknowledges having any of the listed diseases or conditions, the client is not a candidate for the WealthSure Life product. For alternative product ideas, call EquiTrust Sales Support at 800-811-9733.• Illustrations: Return signed copy and Illustration Acknowledgement form with the application.• Telephone Underwriting Interview: Mid-America Agency Services (MAAS)/Hooper Holmes will facilitate the interview on behalf of EquiTrust Life. The interview will take 20–25 minutes. • Point-of-sale interview: Call MAAS/Hooper Holmes at 800-577-5844 during regular business hours: Mon – Thurs 8 AM – 9 PM CST or Friday 8 AM – 5 PM CST. A few questions will be directed to you and all other questions directed to your client. • Interview at a later date: Please provide the information below. MAAS/Hooper Holmes will attempt to contact your client at the designated time. You need not be present for interviews scheduled at a later date. • Interview preparation: Your client should have available the names and addresses for all physicians; dates of physician and facility visits; current medications and dosages; details of injuries, conditions and illnesses; and their Social Security number.• Application: Fax the completed application and this form to EquiTrust at 515-226-5103. The underwriting process will not begin until the application and this form are received. You will be notified by email of approval/decline. You may also check on the website at the “Pending Business” link.• Mail all appropriate forms and the premium check (or transfer form) to EquiTrust: • Standard: EquiTrust Life Insurance Company, PO Box 14500, Des Moines, IA 50306-3500 • Overnight: EquiTrust Life Insurance Company, 7100 Westown Pkwy Suite 200, West Des Moines, IA 50266-2521

Telephone Interview – Choose One: My client has completed the telephone interview with MAAS/Hooper Holmes. The interview was completed:

Date:

My client wishes to be called by MAAS/Hooper Holmes. Best time of day for MAAS/Hooper Holmes to call:

Time: AM/PM Time Zone:

ETL-WSL-SELLGUIDE (1-14)SALES SUPPOrT: 800-811-9733 Email: [email protected]

Page 1 of 9

Policy #

(Home Office Use Only)

Producer Name Full Office Address Office Phone # Producer # % #1

#2

All references to "the Company" shall mean EquiTrust Life Insurance Company of West Des Moines, Iowa, 50266. SECTION A – PROPOSED INSURED AND BENEFICIARY INFORMATION Complete Name of Insured (first-middle-last)

Sex

Age

Birth Date Birth State Social Security Number Height Weight

Residential Address City State ZIP

Telephone (Day and Evening) Email Address

Primary Beneficiary(ies) (attach separate list if needed) SSN/TIN Relationship to Proposed Insured

Contingent Beneficiary(ies) (attach separate list if needed) SSN/TIN Relationship to Proposed Insured

Check here if you are attaching additional Beneficiary information. Check here if the trust will be an owner of the Policy, and also complete the Trust Information Form, ET-TRUST-2502.

SECTION B – OWNER (IF OTHER THAN PROPOSED INSURED) (IF LEFT BLANK, OWNER WILL BE THE SAME AS THE INSURED) Complete Name of Owner (first-middle-last) Birth Date Social Security Number Relationship to Proposed

Insured Telephone (Day and Evening) Email Address

Residential Address City State ZIP

Complete Name of Contingent Owner (if any) - (first-middle-last) Relationship of any Contingent Owner to Proposed Insured

SECTION C – INSURANCE PRODUCT APPLIED FOR

Product Premium Amount $ SECTION D – PERSONAL HISTORY QUESTIONS 1. Have you ever had life or health insurance declined, non-renewed, rated, modified, postponed or

cancelled? Yes No

2. Have you used any form of tobacco or nicotine-based products in the last 24 months? Yes No 3. Within the past 2 years have you: a. Flown or do you intend to fly as a pilot or crew member of any aircraft? b. Engaged in sky diving, hang gliding, scuba or skin diving, vehicle racing, mountain or rock climbing or rodeo activities?

Yes No

Yes No

4. Within the past 10 years have you: a. Used illegal drugs, been treated or advised to have treatment for alcohol or drug use,

(including prescription drugs)? b. Been convicted of or awaiting trial for a felony or are you currently on probation or parole?

Yes No

Yes No

5. Within the past 5 years have you had a DUI/DWI? Yes No

6. Within the past 3 years have you had more than one motor vehicle accident or moving violation? Yes No 7. Do you anticipate residence or travel for more than 3 months outside the United States, Canada or

Mexico during the next 12 months? Yes No

8. Are you a citizen of the United States? Yes No

EquiTrust Life Insurance Company 7100 Westown Pkwy Suite 200 West Des Moines IA 50266-2521

INDIVIDUAL LIFE INSURANCE APPLICATION

ICC11-ETL-SPAPP(03-11)-1

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SECTION E – HEALTH QUESTIONS 1. Has any person proposed for coverage been treated, diagnosed, or given medical advice by

a member of the medical profession for:

a. Uncontrolled high blood pressure, chest pain, heart attack or failure, irregular heart rhythm, heart surgery, stroke or any other disease or disorder of the heart or blood vessels?

Yes No

b. Cancer, melanoma, leukemia or had more than one occurrence of cancer in your lifetime (excluding basal or squamous cell skin cancer)?

Yes No

c. Diabetes, hepatitis, organ transplant, unexplained weight loss over 10 pounds, any disease or disorder of the liver, kidney (including dialysis) or digestive system?

Yes No

d. Emphysema or any other chronic lung or respiratory disorder? Yes No e. Epilepsy, seizures, Alzheimer’s Disease, dementia, memory loss, mental or nervous disorder,

including depression or anxiety? Yes No

f. High cholesterol? Yes No g. Anemia or any other disease or disorder of the blood or immune system (excluding HIV/AIDS)? Yes No h. Any disease or disorder of the muscles, bones or joints? Yes No i. Any other disease or disorder not listed above? Yes No

2. Has any person proposed for coverage been diagnosed by a member of the medical profession or tested positive for the Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS)?

Yes No 3. Within the past 12 months have you been or advised by a member of the medical

profession: a. To be hospitalized, confined to a nursing home, hospice, convalescent, long term care,

assisted living, or mental facility, or diagnosed with a terminal illness (life expectancy of 12 months or less)?

b. To have or have scheduled a surgical operation, diagnostic test, or evaluation that has not yet been completed, except those tests related to the Human Immunodeficiency Virus (AIDS virus)?

Yes No

Yes No

4. Are you currently under treatment or taking prescription medication? Yes No 5. Have you seen a doctor or other medical professional in the past 12 months? Yes No

6. Within the past 5 years, have you been unable to perform or do you require supervision or assistance in performing the activities of daily living – dressing, eating, ambulating, toileting, transferring or bathing?

Yes No

Provide details of all “Yes” answers from Sections D and E in the area below (Use comments section if additional space is needed.) Question # Explanation Dates/Duration Name of Medical Professional

SECTION F – COMMENTS (SPECIAL REQUESTS, REMARKS AND CORRECTIONS OR ENDORSEMENTS)

(Attach a separate sheet if more space is needed.)


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SECTION G – EXISTING COVERAGE/REPLACEMENT 1. Does either the Owner or Proposed Insured have any other life insurance policies or

annuity contracts? If "Yes" and required by your state, complete the Replacement Notice.

Yes No

2. Is the Policy applied for replacing or likely to replace any existing life insurance or annuity contracts? If "Yes," complete any required Replacement Notice.

Yes No

3. Are values from an existing life insurance policy or annuity being used to pay

premiums on the new Policy? If "Yes" and required by your state, complete the Replacement Notice.

Yes No

SECTION H – ADDITIONAL QUESTIONS Details to each “Yes” answer 1. Will the Proposed Owner and/or Beneficiary,

and/or any entity on the Proposed Owner’s behalf, receive any compensation, whether via the form of cash, property, an agreement to pay money in the future, a percentage of the death benefit, or otherwise if this Policy is issued?

Yes No

2. Has the Proposed Owner been involved in any discussion about the possible sale or assignment of this Policy or a beneficial interest in a trust, LLC, or other entity created on the Owner’s behalf?

Yes No If “yes”, provide details and a copy of the applicable entity’s controlling documents.

3. Is this Policy being funded via a premium financing loan or with funds borrowed, advanced or paid from another person or entity?

Yes No

4. Has any party to the application such as the Applicant, Proposed Insured, Owner, or any Beneficiary ever sold, transferred or assigned any life insurance to a third party, such as a viatical settlement entity, life settlement entity, insurance company, other secondary market provider, or premium financing entity?

Yes No

NOTICE: State insurance law may prohibit the owner of a life insurance policy from entering into any agreement to sell, transfer or assign a life insurance policy prior to the date the policy was issued, or within a period of time specified by state law after the policy was issued. You should consult with legal advisors if you have any questions about these matters.

ICC11-ETL-122(03-11)-3

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SECTION I – REPRESENTATIONS AND AGREEMENTS

It is understood that EquiTrust Life Insurance Company (“the Company”) has the right to call you for a follow up phone interview and/or require a medical examination. This Application is not complete until any required phone interview and/or medical examination has been performed.

Facsimile or electronic transmission of this signed, original Application and retransmission of any signed facsimile or electronic transmission thereof shall be the same as delivery of an original. Each party agrees that delivery of this Application by facsimile or electronic transmission as provided above shall be evidence of the execution and delivery of the Application by all parties to the same extent that an original signature could be used. The preceding notwithstanding, at the request of EquiTrust Life Insurance Company, the other party will confirm facsimile or electronically transmitted signatures by signing an original document.

CERTIFICATION Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be

issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been

notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and

3. I am a U.S. person (including a U.S. resident alien). Certification instructions. You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, Item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN.

By signing this Application, I represent that the statements and answers in all parts of the Application and Supplements thereto are true and complete to the best of my knowledge and belief and it is agreed that:

1. I have read the Application and all statements as they pertain to the Proposed Insured or Owner. 2. The statements and answers in this Application will be relied upon and form the basis of any insurance. 3. No agent or any other person, except an officer of the Company, can make or change any insurance contract or bind the

Company by making promises regarding any contract. Any change must be in writing and signed by an officer of the Company.

4. In the case of any apparent errors or omissions found by the Company in this Application, the Company is hereby authorized to amend the same by recording the change in the space provided in Section F.

5. Except as specified in the Temporary Insurance Agreement, no insurance shall take effect unless and until the following conditions are met:

(a) the Policy as applied for has been approved by the Company in its Administrative Office, or if the Policy is issued other than as applied for, the Policy has been physically received and accepted by the Owner;

(b) the first premium has been paid; and (c) no change in heath and insurability of any Proposed Insured has occurred to the best of any Owner’s or Proposed

Insured’s knowledge between the date of the Application and the date the conditions in (a) and (b) of this paragraph are both satisfied.

6. No change in amount, age at issue, premium class, plan of insurance, or benefits shall be effective without the written consent of the Owner and the Proposed Insured.

7. I have read the Important Notice Regarding Sales to Military Personnel, if applicable. Federal law requires that sufficient information to identify the parties to the purchase of a policy be obtained, and failure to provide such information could result in the policy not being issued, being delayed, unprocessed transaction requests, or policy termination.

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. The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid back up withholding.

________________________________________________Signed at: City and State

Signature of Proposed Insured Date

Signature of Owner (if other than a Proposed Insured) Date

Signature of Producer Date


Page 5 of 9 – Incomplete without all pages

SECTION J – AUTHORIZATION AND ACKNOWLEGEMENT STATEMENT

THIS IS A HIPAA COMPLIANT AUTHORIZATION

EquiTrust Life Insurance Company (“the Company”) or its reinsurers may obtain information about me or my minor children from: any physician, medical professional, hospital, medical care facility, government agency, public records, employer, insurance company or institution, consumer reporting agency, pharmacies, pharmacy benefit managers, Insurance Laboratory, Veterans Administration, MIB, Inc., or any other person or organization that has any record of information about me. The purpose is to determine eligibility for insurance or benefits. The Company or its reinsurers may obtain personal information and any records available as to diagnosis, care, treatment and prognosis of any physical or mental condition and/or prescription drug information, and may obtain an investigative consumer report. To facilitate rapid submission of such information, all sources, except MIB, Inc., are authorized to give such information or records to any entity designated by the Company or its reinsurers to collect and transmit such information. This Authorization includes information about mental health care (other than psychotherapy notes), developmental disability care, and drug and alcohol abuse treatment. I understand that: (1) I can revoke this Authorization at any time by written notice to the Company; (2) revocation of this Authorization will not affect any prior action taken by the Company in reliance upon this Authorization; and (3) failure to sign, or revocation of this Authorization may impair the Company’s ability to process applications or evaluate claims and may be a basis for denying this application or a claim for benefits. I further understand and acknowledge that the information authorized for release may include records which may indicate the presence of a communicable or venereal disease, which may include, but are not limited to, diseases such as hepatitis, syphilis, gonorrhea, and the Human Immunodeficiency Virus, also known as Acquired Immune Deficiency Syndrome (AIDS). The Company may disclose information to: its reinsurers, those who perform services for the Company or its reinsurers, those companies to which I have applied or may apply for life or health insurance or benefits, and the Company’s affiliates for claims handling, servicing, underwriting, insurance marketing, and other purposes. I authorize the Company, or its reinsurers, to make a brief report of my personal health information to MIB. Disclosure may also be made when required or permitted by law. Some of the health information noted above may be disclosed to persons or organizations that are not subject to federal health information privacy laws, resulting in the information no longer being protected under such laws. I understand that I have the right to see personal information collected about me, and have the right to correct any information which may be wrong. I understand that I may obtain a description of this Company’s information practices by requesting one from my agent of the Company at the address provided with my Policy. This authorization is valid for 24 months from the date signed. A copy of this Authorization will be valid as the original. I have received a copy of this authorization and the Important Notices, and have read the representations on the previous page. The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid back up withholding.

________________________________________________ Signed at: City and State

Signature of Proposed Insured Date Signature of Owner (if other than a Proposed Insured) Date Signature of Producer Date

ETL-122(01-13)-5

Proposed Insured Copy

Page 6 of 9 – Incomplete without all pages

COPY FOR INSURED’S FILES IMPORTANT – MIB, INC.

Information regarding your insurability will be treated as confidential. EquiTrust Life Insurance Company (“the Company”) or its reinsurers may, however, make a brief report thereon to the MIB, Inc., a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB, Inc. member company for life or health insurance coverage, or claim for benefits is submitted to such a company, the MIB, Inc., upon request, will supply such company with the information in its file. Upon receipt of a request from you, the MIB, Inc. will arrange disclosure of any information it may have in your file. (Medical information will be disclosed only to your attending physician.) If you question the accuracy of information in the MIB Inc.’s file, you may contact the MIB, Inc. and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address of the MIB, Inc.’s information office is: 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734 Telephone number (866) 692-6901 The Company or its reinsurers may also release information in its file to other life insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted.

AUTHORIZATION AND ACKNOWLEDGEMENT STATEMENT

The Company or its reinsurers may obtain information about me or my minor children from: any physician, medical professional, hospital, medical care facility, government agency, public records, employer, insurance company or institution, consumer reporting agency, pharmacies, pharmacy benefit managers, Insurance Laboratory, Veterans Administration, MIB, Inc., or any other person or organization that has any record of information about me. The purpose is to determine eligibility for insurance or benefits. The Company or its reinsurers may obtain personal information and any records available as to diagnosis, care, treatment and prognosis of any physical or mental condition and/or prescription drug information, and may obtain an investigative consumer report. To facilitate rapid submission of such information, all sources, except MIB, Inc., are authorized to give such information or records to any entity designated by the Company or its reinsurers to collect and transmit such information. This Authorization includes information about mental health care (other than psychotherapy notes), developmental disability care, and drug and alcohol abuse treatment. I understand that: (1) I can revoke this Authorization at any time by written notice to the Company; (2) revocation of this Authorization will not affect any prior action taken by the Company in reliance upon this Authorization; and (3) failure to sign, or revocation of this Authorization may impair the Company’s ability to process applications or evaluate claims and may be a basis for denying this application or a claim for benefits. I further understand and acknowledge that the information authorized for release may include records which may indicate the presence of a communicable or venereal disease, which may include, but are not limited to, diseases such as hepatitis, syphilis, gonorrhea, and the Human Immunodeficiency Virus, also known as Acquired Immune Deficiency Syndrome (AIDS). The Company may disclose information to: its reinsurers, those who perform services for the Company or its reinsurers, those companies to which I have applied or may apply for life or health insurance or benefits, and the Company’s affiliates for claims handling, servicing, underwriting, insurance marketing, and other purposes. I authorize the Company, or its reinsurers, to make a brief report of my personal health information to MIB. Disclosure may also be made when required or permitted by law. Some of the health information noted above may be disclosed to persons or organizations that are not subject to federal health information privacy laws, resulting in the information no longer being protected under such laws. I understand that I have the right to see personal information collected about me, and have the right to correct any information which may be wrong. I understand that I may obtain a description of this Company’s information practices by requesting one from my agent of the Company at the address provided with my Policy. This authorization is valid for 24 months from the date signed. A copy of this Authorization will be valid as the original. FALSE OR FRAUDULENT INFORMATION

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.

ETL-122(01-13)-5A

ProposedInsuredCopy

Page 7 of 9

FALSE OR FRAUDULENT INFORMATION – COPY FOR INSURED’S FILES

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.

IMPORTANT NOTICE REGARDING SALES TO MILITARY PERSONNEL Please read the following Disclosure if you are an Active Duty Service Member of the United States Armed Forces. You should have received a life insurance illustration at the time you completed the application. If you did not, please request one from your agent or call our office at 866-598-3692. Who is an active duty service member? An active duty service member is a service member engaged in full-time duty in the active military service of the United States and includes members of the reserve component (National Guard and Reserve) while serving under published orders for active duty or full-time training. The term does not include members of the reserve component who are performing active duty or active duty for training under military calls or orders specifying periods of less than 31 calendar days. In accordance with applicable law, the following information is provided with respect to the life insurance policy you have applied for with the Company:

• As a member of the United States Armed Forces, you are advised that subsidized life insurance is available to you under the Servicemembers' Group Life Insurance program (also referred to as `SGLI'). This federally-sponsored program provides up to $400,000 of term life insurance at a cost of $.07 per thousand or $28 per month.

• This policy is not offered or provided by the Federal Government, and the Federal Government has in no way sanctioned, recommended, or encouraged the sale of the life insurance product being offered;

• No person has received any referral fee or incentive compensation in connection with the offer or sale of the life insurance product, unless such person is a licensed agent of the Company;

• The Policy contains a free look period. You may choose to return the Policy during the free look period. If returned to the Company at the address shown on the cover of the Policy, your Policy becomes void, and we will refund your premiums paid (according to the terms stated in the Policy).

If you have any questions or do not understand this disclosure, please visit with your agent.

CERTIFICATION Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. person (including a U.S. resident alien). Certification instructions. You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, Item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN.


Page 8 of 9

TEMPORARY INSURANCE AGREEMENT This Agreement provides a limited amount of life insurance coverage for a limited period of time. No insurance is provided under this Agreement unless all the conditions and limitations of the Agreement are met.

TEMPORARY INSURANCE In consideration of receiving your payment, we provide the following temporary insurance on the life of the Proposed Insured. If all conditions and limitations of this Agreement are met, coverage under this Agreement begins on the date of the Application. In no event will insurance coverage exist under both the Temporary Insurance Agreement and the Policy simultaneously. We will pay the Beneficiary(ies) designated in the Application the amount of life insurance you applied for, or $150,000, whichever is less, if: 1. The Application has been completed; and 2. All representations on the Application are true and complete; and 3. The Proposed Insured dies as the result of any cause other than suicide; and 4. This Agreement has not terminated. In the event that any other temporary insurance agreements are in existence at the time of the Proposed Insured’s death, $150,000 is the aggregate liability under all temporary life insurance agreements.

The following limitations apply to this Temporary Insurance Agreement: 1. Fraud or material misrepresentation in the Application or in the answers to the health questions of this Agreement

invalidates this Agreement and the Application, and the Company’s only liability is for refund of any payment made. 2. No one is authorized to waive or modify any of the provisions of this Agreement. 3. This Agreement provides no insurance for riders or additional benefits. 4. There is no coverage under this Agreement if no money is submitted with this Application or if the check or

bank draft submitted for payment is not honored by the financial institution.DATE COVERAGE TERMINATES - 60 DAY MAXIMUM Temporary life insurance under this Agreement terminates automatically at the earliest of: 1. 60 days from the date of this Agreement; 2. The date insurance takes effect under the Policy applied for; 3. The date a Policy, other than as applied for, is offered to and accepted by the Owner; 4. The date the Company mails notice to the Owner that we have stopped considering the Application; or 5. The date the Company mails notice of termination of coverage and refunds the payment to the Owner. The

Company may terminate this coverage at any time.

HEALTH QUESTIONS – HAS THE PROPOSED INSURED: 1. Within the past 90 days, been admitted to a hospital or other medical facility, been advised to be admitted, or had

surgery performed or recommended? For purposes of this question, “admitted” is considered to be 12 continuous hours in the facility. Yes No

2. Within the past 2 years, been treated for chest pain, heart trouble, stroke, or cancer, or had such treatment recommended by a physician or other practitioner? Yes No

If either Question #1 or Question #2 above is answered “Yes” or left blank, no coverage will take effect under the Temporary Life Insurance Agreement. I have read and received a copy of this Agreement and declare that the answers are true to the best of my knowledge and belief. I understand and agree to all of its terms. A sum of $______________ has been paid with the Application for life insurance to EquiTrust Life Insurance Company.

Dated at (city and state) ____________ On (date) ______________

_____ Signature of Proposed Insured

______ Signature of Proposed Owner (if other than Proposed Insured)

_____ Signature of Agent

ICC11-ETL-SPAPP(03-11)-TIA


OwnerCopy

Page 9 of 9

TEMPORARY INSURANCE AGREEMENT This Agreement provides a limited amount of life insurance coverage for a limited period of time. No insurance is provided under this Agreement unless all the conditions and limitations of the Agreement are met.

TEMPORARY INSURANCE In consideration of receiving your payment, we provide the following temporary insurance on the life of the Proposed Insured. If all conditions and limitations of this Agreement are met, coverage under this Agreement begins on the date of the Application. In no event will insurance coverage exist under both the Temporary Insurance Agreement and the Policy simultaneously. We will pay the Beneficiary(ies) designated in the Application the amount of life insurance you applied for, or $150,000, whichever is less, if: 1. The Application has been completed; and 2. All representations on the Application are true and complete; and 3. The Proposed Insured dies as the result of any cause other than suicide; and 4. This Agreement has not terminated. In the event that any other temporary insurance agreements are in existence at the time of the Proposed Insured’s death, $150,000 is the aggregate liability under all temporary life insurance agreements.

The following limitations apply to this Temporary Insurance Agreement: 1. Fraud or material misrepresentation in the Application or in the answers to the health questions of this Agreement

invalidates this Agreement and the Application, and the Company’s only liability is for refund of any payment made. 2. No one is authorized to waive or modify any of the provisions of this Agreement. 3. This Agreement provides no insurance for riders or additional benefits. 4. There is no coverage under this Agreement if no money is submitted with this Application or if the check or

bank draft submitted for payment is not honored by the financial institution.DATE COVERAGE TERMINATES - 60 DAY MAXIMUM Temporary life insurance under this Agreement terminates automatically at the earliest of: 1. 60 days from the date of this Agreement; 2. The date insurance takes effect under the Policy applied for; 3. The date a Policy, other than as applied for, is offered to and accepted by the Owner; 4. The date the Company mails notice to the Owner that we have stopped considering the Application; or 5. The date the Company mails notice of termination of coverage and refunds the payment to the Owner. The

Company may terminate this coverage at any time.

HEALTH QUESTIONS – HAS THE PROPOSED INSURED: 1. Within the past 90 days, been admitted to a hospital or other medical facility, been advised to be admitted, or had

surgery performed or recommended? For purposes of this question, “admitted” is considered to be 12 continuous hours in the facility. Yes No

2. Within the past 2 years, been treated for chest pain, heart trouble, stroke, or cancer, or had such treatment recommended by a physician or other practitioner? Yes No

If either Question #1 or Question #2 above is answered “Yes” or left blank, no coverage will take effect under the Temporary Life Insurance Agreement. I have read and received a copy of this Agreement and declare that the answers are true to the best of my knowledge and belief. I understand and agree to all of its terms. A sum of $______________ has been paid with the Application for life insurance to EquiTrust Life Insurance Company.

Dated at (city and state) ____________ On (date) ______________

_____ Signature of Proposed Insured

______ Signature of Proposed Owner (if other than Proposed Insured)

_____ Signature of Agent

ICC11-ETL-SPAPP(03-11)-TIA


PRODUCER CERTIFICATE – EXISTING INSURANCE/REPLACEMENT TRANSACTIONS To be completed by the agent. I certify that I have asked the person proposed for coverage all of the questions contained in this Application and have accurately recorded on this Application the information supplied by the person proposed for coverage. 1. Did you fax the Application and the fax cover sheet to EquiTrust Life Insurance Company? Yes No 2. Did you provide the brochure to the Proposed Insured? Yes No 3. Did you advise the Proposed Insured(s) that they may be contacted by the Company or its

authorized representative for the completion of a telephone interview? Yes No 4. Did you use only insurer-approved sales materials with this Application and leave an original or copy

of all sales materials with the Owner? Yes No 5. Did you or will you provide a printed copy of electronically presented sales materials to the Owner no

later than the date the Policy is delivered? Yes No Send all supporting documents to expedite the application process. QUESTIONS REGARDING FIELD UNDERWRITING6. Did you see all persons proposed for insurance? Yes No If “no”, explain: ________________________________________________________________________________ 7. How long have you known the Applicant and Proposed Insured(s)? ________________ Related? Yes No 8. Were you approached for this insurance? Yes No If “yes”, explain: _______________________________________________________________________________ 9. If the Beneficiary is not a relative or business associate, explain fully the insurable interest. _______________________________________________________________________________________________________ 10. Spouse’s name and amount of life insurance in force. _______________________________________________________ 11. Purpose of Insurance: Human Life Value (Income Needs) Cash Needs Estate Needs Maximize Pension Business Insurance – give details Social Security Offset Debt Protection Trust Funding Other (explain): 12. Did you ask all required questions in the Application and record the answers in the Insured(s)

presence exactly as provided by the Proposed Insured? Yes No 13. Are you aware of any Proposed Insured(s) health conditions, not otherwise disclosed in the

Application that could impact underwriting results? Yes No If “yes”, explain: ______________________________________________________________________________________ QUESTIONS REGARDING REPLACEMENT 14. Does either the Owner or Proposed Insured have any other life insurance policies or annuity

contracts? If “Yes” and required by your state, complete the Replacement Notice. Yes No 15. Will this plan replace any existing life insurance or annuity? (Using the definition of Replacement

adopted by your state.) If “Yes”, complete any required Replacement Notice. Yes No 16. Are values from an existing life insurance policy or annuity being used to pay premiums on the new

policy? If “Yes” and required by your state, complete the Replacement Notice. Yes No If questions 15 and 16 are “Yes,” explain the reason for the replacement (including any proposed replacement): ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 17. For any replacement, indicate the type of coverage proposed to be replaced: Term Life Whole Life Variable Life Fixed Annuity Variable Annuity Other – be specific 18. I certify that this Application is in accordance with the Company’s written statement of the Company’s position with

respect to the acceptability of replacements. If “not”, please explain: __________________________________________________________________________________ _____________________________________________________________________________________________________

NOTE: For replacements subject to the Model Life Insurance and Annuity Replacement Regulation, copies of any individualized sales material (including illustrations) must be submitted with the Application.

19. Is there a simultaneous application submitted to any other company? Yes No Company ____________________________________________ Amount $_____________________ Will all be accepted, if issued? Yes No 20. I have verified the identity of the Applicant by viewing their driver’s license or other government

issued form of identification. Yes No

Signature of Producer Date

ICC11-ETL-SPAPP(03-11)-PRODCERT

Please review this disclosure document carefully. DISTRIBUTIONS FROM THIS POLICY MAY BE TAXABLE - This policy will likely be classified as a Modified Endowment Contract (MEC) under Section 7702A of the Internal Revenue Code. Distributions from a MEC, including loans, partial withdrawals, and surrenders, are taxed as income first and recovery of basis second. Distributions may be subject to a 10% federal income tax penalty unless one of several exceptions is met. This manner of taxation differs from non-MEC life insurance policies. You should consult a qualified tax professional regarding the tax consequences of receiving distributions from your policy. POLICY SURRENDER CHARGES MAY APPLY - A surrender charge will be deducted from any partial withdrawal or full surrender taken in the first ten policy years. This will reduce the amount of proceeds you receive. After the first policy year you may take an annual penalty-free withdrawal up to 5% of your accumulation value. However, if you surrender your policy in the same year that you have taken a penalty-free withdrawal, a surrender charge will be assessed on the amount of the penalty-free withdrawal. The surrender charge is 10% in year one; 9% in year two; 8% in year three; 7% in year four; 6% in year five; 5% in year six; 4% in year seven; 3% in year eight; 2% in year nine; 1% in year ten; and 0% thereafter. THIS POLICY MAY LAPSE IF YOUR LOAN BALANCE EXCEEDS THE CASH SURRENDER VALUE - Your policy will lapse (terminate) if the loan balance is greater than the cash surrender value. Loan interest is charged annually at the end of each policy year. If you do not pay back the entire loan interest when it is due, the unpaid loan interest will be added (accrued) to your loan balance and interest will be charged each year on the accrued interest as well. If the loan balance grows to the point where it is greater than the cash surrender value, your policy will lapse. If your policy lapses, no death benefit will be payable upon the insured person’s death. It is possible that the lapse of a policy will be a taxable event. DEATH BENEFIT PAYMENT – No death benefit will be paid under this policy unless the policy is in force at the time of the insured’s death. The death benefit will be reduced by the amount of any outstanding loan balance. Any withdrawals taken while the policy is in force will reduce the death benefit proportionally. POLICY FEES AND EXPENSE CHARGES – The policy accumulation value will be reduced by a monthly cost of insurance charge, a one-time 15% premium load on the policy date, and a monthly policy fee will be assessed as follows: $8 per month in policy year 1, $3 per month in policy years 2-20, and none thereafter. Please review your policy for details.

Proposed Insured Signature Date

Owner's Signature (if other than Proposed Insured)

Date

Agent’s Signature Date

WEALTHSURE LIFE™ INSURANCE PRODUCT DISCLOSURE

Form Series ICC11-ETL-ISWL-2000(03-11)

EquiTrust Life Insurance Company • 7100 Westown Pkwy Suite 200 • West Des Moines, IA 50266-2521 866-598-3692

ICC11-ETL-WSL-1101 (10-13) COMPANY COPY

Page 1 of 1

Please review this disclosure document carefully. DISTRIBUTIONS FROM THIS POLICY MAY BE TAXABLE - This policy will likely be classified as a Modified Endowment Contract (MEC) under Section 7702A of the Internal Revenue Code. Distributions from a MEC, including loans, partial withdrawals, and surrenders, are taxed as income first and recovery of basis second. Distributions may be subject to a 10% federal income tax penalty unless one of several exceptions is met. This manner of taxation differs from non-MEC life insurance policies. You should consult a qualified tax professional regarding the tax consequences of receiving distributions from your policy. POLICY SURRENDER CHARGES MAY APPLY - A surrender charge will be deducted from any partial withdrawal or full surrender taken in the first ten policy years. This will reduce the amount of proceeds you receive. After the first policy year you may take an annual penalty-free withdrawal up to 5% of your accumulation value. However, if you surrender your policy in the same year that you have taken a penalty-free withdrawal, a surrender charge will be assessed on the amount of the penalty-free withdrawal. The surrender charge is 10% in year one; 9% in year two; 8% in year three; 7% in year four; 6% in year five; 5% in year six; 4% in year seven; 3% in year eight; 2% in year nine; 1% in year ten; and 0% thereafter. THIS POLICY MAY LAPSE IF YOUR LOAN BALANCE EXCEEDS THE CASH SURRENDER VALUE - Your policy will lapse (terminate) if the loan balance is greater than the cash surrender value. Loan interest is charged annually at the end of each policy year. If you do not pay back the entire loan interest when it is due, the unpaid loan interest will be added (accrued) to your loan balance and interest will be charged each year on the accrued interest as well. If the loan balance grows to the point where it is greater than the cash surrender value, your policy will lapse. If your policy lapses, no death benefit will be payable upon the insured person’s death. It is possible that the lapse of a policy will be a taxable event. DEATH BENEFIT PAYMENT – No death benefit will be paid under this policy unless the policy is in force at the time of the insured’s death. The death benefit will be reduced by the amount of any outstanding loan balance. Any withdrawals taken while the policy is in force will reduce the death benefit proportionally. POLICY FEES AND EXPENSE CHARGES – The policy accumulation value will be reduced by a monthly cost of insurance charge, a one-time 15% premium load on the policy date, and a monthly policy fee will be assessed as follows: $8 per month in policy year 1, $3 per month in policy years 2-20, and none thereafter. Please review your policy for details.

Proposed Insured Signature Date


Date


WEALTHSURE LIFE™ INSURANCE PRODUCT DISCLOSURE

Form Series ICC11-ETL-ISWL-2000(03-11)


ICC11-ETL-WSL-1101 (10-13) APPLICANT COPY

Page 1 of 1

This Rider provides for an acceleration of the Death Benefit, payable to the Policy Owner during the lifetime of the Insured, if the Insured is diagnosed as Terminally Ill or Chronically Ill after the Rider effective date. This Rider is not long-term care insurance and does not provide long-term care benefits. There is no restriction on the use of the Accelerated Death Benefit proceeds. The benefits paid under this Rider may or may not be taxable. You should seek advice from a qualified tax advisor about the circumstances under which you could receive Accelerated Death Benefit payments excludable from income under federal law. The receipt of Accelerated Death Benefit payments may affect your eligibility for Medicaid or other government benefits or entitlements and may have income tax consequences. Rider Benefits • Terminal Illness Benefit is available as a lump sum of up to 100% of the Death Benefit, and is triggered if

the Insured is diagnosed as Terminally Ill. • Nursing Care Confinement Benefit is available as 1/36 of the Death Benefit payable for 36 months, and is

triggered if the Insured is diagnosed as Chronically Ill, has been confined continuously for 90 days to a Qualified Nursing Care Facility, and the confinement is expected to be permanent. This benefit is also available as a lump sum of up to 100% of the Death Benefit.

• Chronic Care Benefit is available as 1/60 of the Death Benefit payable for 60 months, and is triggered if the Insured is diagnosed as Chronically Ill. This benefit is also available as a lump sum of up to 100% of the Death Benefit.

Effect of Benefit Payments on Policy Values When an Accelerated Death Benefit is paid under this Rider: • The Death Benefit of the Policy will be reduced by the Accelerated Death Benefit; and • The Face Amount, Accumulation Value, the Minimum Accumulation Value, and the Guaranteed Tabular Cash

Value will all be reduced in proportion to the Accelerated Death Benefit; and • If there is a Policy loan, a payment will be made on the Loan Balance from the proceeds. The amount of this

payment will be in the same proportion to the Loan Balance as the amount of the Accelerated Death Benefit is to the Death Benefit.

Charges and Fees • There is no premium charge for this Rider. • If benefits are elected under this Rider, a one-time $250 administrative fee will be deducted from the

Accelerated Death Benefit prior to determining any benefit payments. Lump Sum Example 1: Terminal Illness without policy loan Prior to acceleration: After $25,000 (25% of Death Benefit) acceleration: Death Benefit $100,000 Remaining Death Benefit $75,000 Cash Value $80,000 Remaining Cash Value $60,000 Lump Sum Example 2: Terminal Illness with policy loan Prior to acceleration: After $25,000 (25% of Death Benefit) acceleration: Death Benefit $100,000 Remaining Death Benefit $75,000 Cash Value $80,000 Remaining Cash Value $60,000 Policy Loan $20,000 Remaining Policy Loan $15,000 Monthly Benefit Example 3: Nursing Care Confinement monthly benefit without policy loan Prior to acceleration: After first monthly benefit (1/60 of Death Benefit): Death Benefit $100,000 Remaining Death Benefit $98,333 Cash Value $80,000 Remaining Cash Value $78,667

ACCELERATED DEATH BENEFIT RIDER DISCLOSURE STATEMENT


COMPANY COPY Page 1 of 2 – Incomplete without all pages

ICC11-ETL-ABD (03-11)

Monthly Benefit Example 4: Nursing Care Confinement monthly benefit with policy loan Prior to acceleration: After first monthly benefit (1/60 of Death Benefit): Death Benefit $100,000 Remaining Death Benefit $98,333 Cash Value $80,000 Remaining Cash Value $78,667 Policy Loan $20,000 Remaining Policy Loan $19,667 Payment of Benefits • The payment of the Accelerated Death Benefit is due immediately upon receipt of due written proof of

eligibility. • You may elect to receive benefits only once. • If a lump sum payment is elected, the payment will be no less than the acceleration percentage multiplied by

the difference between the current Policy Accumulation Value and any outstanding Policy Loans. • Benefits are payable under the provision for which the Insured qualifies and the Owner elects. You may only

elect one benefit even if the Insured qualifies under more than one. • The Death Benefit less Loan Balance will be payable if you elect to accelerate less than 100% of the Death

Benefit, if you elect to stop receiving monthly payments, upon death of the Insured, or if the Insured dies before all payments of the Accelerated Death Benefit are made.

Definitions Death Benefit means, for the purposes of the Rider, the greater of the following two amounts: 1) The Face Amount on the date that the Accelerated Death Benefit is processed less any Loan Balance; or 2) The greater of the Accumulation Value or the Minimum Guaranteed Cash Value on the date that the

Accelerated Death Benefit is processed, multiplied by the Minimum Required Death Benefit Percentage for the Insured's attained Age, sex and Premium Class, less any Loan Balance.

Terminally Ill means an individual who has been certified by a Physician as having an illness or physical condition which can reasonably be expected to result in death in 12 months or less after the date of certification. Chronically Ill means a person who has been certified by a Physician as: 1) being unable to perform, without substantial assistance, at least two of six Activities of Daily Living (ADL) for at least 90 days due to a loss of functional capacity; or 2) requiring substantial supervision to protect the individual from threats to health and safety due to severe cognitive impairment as certified by a Physician within the preceding 12-month period. Qualified Nursing Facility means a skilled nursing care facility, intermediate care facility or custodial care facility. It is not: (a) a hospital; (b) a facility that primarily treats persons who are chemically dependent or mentally ill; (c) a home for the aged, a community living center, or a place that primarily provides domiciliary residency or retirement care in the absence of medical necessity; or (d) a facility owned or operated by a member of the Policy Owner’s or the Insured’s immediate family. A Qualified Nursing Facility must be licensed as a care facility by the state in which it operates and must conduct its business in accordance with law. Lump Sum Discount Factor means an interest adjustment for the advanced payment of elected proceeds, if a lump sum payment is elected. The factor will be based on an annual interest rate that will be no more than the greater of the current yield on 90 day Treasury Bills or the current maximum statutory adjustable policy loan interest rate. The discount factors are: Terminal Illness Benefit – 95%; Nursing Care Confinement Benefit – 85%; Chronic Care Benefit – 75%.

Proposed Insured Signature

Date


Date



COMPANY COPY Page 2 of 2 – Incomplete without all pages ICC11-ETL-ABD (03-11)

This Rider provides for an acceleration of the Death Benefit, payable to the Policy Owner during the lifetime of the Insured, if the Insured is diagnosed as Terminally Ill or Chronically Ill after the Rider effective date. This Rider is not long-term care insurance and does not provide long-term care benefits. There is no restriction on the use of the Accelerated Death Benefit proceeds. The benefits paid under this Rider may or may not be taxable. You should seek advice from a qualified tax advisor about the circumstances under which you could receive Accelerated Death Benefit payments excludable from income under federal law. The receipt of Accelerated Death Benefit payments may affect your eligibility for Medicaid or other government benefits or entitlements and may have income tax consequences. Rider Benefits • Terminal Illness Benefit is available as a lump sum of up to 100% of the Death Benefit, and is triggered if

the Insured is diagnosed as Terminally Ill. • Nursing Care Confinement Benefit is available as 1/36 of the Death Benefit payable for 36 months, and is

triggered if the Insured is diagnosed as Chronically Ill, has been confined continuously for 90 days to a Qualified Nursing Care Facility, and the confinement is expected to be permanent. This benefit is also available as a lump sum of up to 100% of the Death Benefit.

• Chronic Care Benefit is available as 1/60 of the Death Benefit payable for 60 months, and is triggered if the Insured is diagnosed as Chronically Ill. This benefit is also available as a lump sum of up to 100% of the Death Benefit.

Effect of Benefit Payments on Policy Values When an Accelerated Death Benefit is paid under this Rider: • The Death Benefit of the Policy will be reduced by the Accelerated Death Benefit; and • The Face Amount, Accumulation Value, the Minimum Accumulation Value, and the Guaranteed Tabular Cash

Value will all be reduced in proportion to the Accelerated Death Benefit; and • If there is a Policy loan, a payment will be made on the Loan Balance from the proceeds. The amount of this

payment will be in the same proportion to the Loan Balance as the amount of the Accelerated Death Benefit is to the Death Benefit.

Charges and Fees • There is no premium charge for this Rider. • If benefits are elected under this Rider, a one-time $250 administrative fee will be deducted from the

Accelerated Death Benefit prior to determining any benefit payments. Lump Sum Example 1: Terminal Illness without policy loan Prior to acceleration: After $25,000 (25% of Death Benefit) acceleration: Death Benefit $100,000 Remaining Death Benefit $75,000 Cash Value $80,000 Remaining Cash Value $60,000 Lump Sum Example 2: Terminal Illness with policy loan Prior to acceleration: After $25,000 (25% of Death Benefit) acceleration: Death Benefit $100,000 Remaining Death Benefit $75,000 Cash Value $80,000 Remaining Cash Value $60,000 Policy Loan $20,000 Remaining Policy Loan $15,000 Monthly Benefit Example 3: Nursing Care Confinement monthly benefit without policy loan Prior to acceleration: After first monthly benefit (1/60 of Death Benefit): Death Benefit $100,000 Remaining Death Benefit $98,333 Cash Value $80,000 Remaining Cash Value $78,667

ACCELERATED DEATH BENEFIT RIDER DISCLOSURE STATEMENT


APPLICANT COPY Page 1 of 2 – Incomplete without all pages

ICC11-ETL-ABD (03-11)

Monthly Benefit Example 4: Nursing Care Confinement monthly benefit with policy loan Prior to acceleration: After first monthly benefit (1/60 of Death Benefit): Death Benefit $100,000 Remaining Death Benefit $98,333 Cash Value $80,000 Remaining Cash Value $78,667 Policy Loan $20,000 Remaining Policy Loan $19,667 Payment of Benefits • The payment of the Accelerated Death Benefit is due immediately upon receipt of due written proof of

eligibility. • You may elect to receive benefits only once. • If a lump sum payment is elected, the payment will be no less than the acceleration percentage multiplied by

the difference between the current Policy Accumulation Value and any outstanding Policy Loans. • Benefits are payable under the provision for which the Insured qualifies and the Owner elects. You may only

elect one benefit even if the Insured qualifies under more than one. • The Death Benefit less Loan Balance will be payable if you elect to accelerate less than 100% of the Death

Benefit, if you elect to stop receiving monthly payments, upon death of the Insured, or if the Insured dies before all payments of the Accelerated Death Benefit are made.

Definitions Death Benefit means, for the purposes of the Rider, the greater of the following two amounts: 1) The Face Amount on the date that the Accelerated Death Benefit is processed less any Loan Balance; or 2) The greater of the Accumulation Value or the Minimum Guaranteed Cash Value on the date that the

Accelerated Death Benefit is processed, multiplied by the Minimum Required Death Benefit Percentage for the Insured's attained Age, sex and Premium Class, less any Loan Balance.

Terminally Ill means an individual who has been certified by a Physician as having an illness or physical condition which can reasonably be expected to result in death in 12 months or less after the date of certification. Chronically Ill means a person who has been certified by a Physician as: 1) being unable to perform, without substantial assistance, at least two of six Activities of Daily Living (ADL) for at least 90 days due to a loss of functional capacity; or 2) requiring substantial supervision to protect the individual from threats to health and safety due to severe cognitive impairment as certified by a Physician within the preceding 12-month period. Qualified Nursing Facility means a skilled nursing care facility, intermediate care facility or custodial care facility. It is not: (a) a hospital; (b) a facility that primarily treats persons who are chemically dependent or mentally ill; (c) a home for the aged, a community living center, or a place that primarily provides domiciliary residency or retirement care in the absence of medical necessity; or (d) a facility owned or operated by a member of the Policy Owner’s or the Insured’s immediate family. A Qualified Nursing Facility must be licensed as a care facility by the state in which it operates and must conduct its business in accordance with law. Lump Sum Discount Factor means an interest adjustment for the advanced payment of elected proceeds, if a lump sum payment is elected. The factor will be based on an annual interest rate that will be no more than the greater of the current yield on 90 day Treasury Bills or the current maximum statutory adjustable policy loan interest rate. The discount factors are: Terminal Illness Benefit – 95%; Nursing Care Confinement Benefit – 85%; Chronic Care Benefit – 75%.

Proposed Insured Signature

Date


Date



APPLICANT COPY Page 2 of 2 – Incomplete without all pages ICC11-ETL-ABD (03-11)

Please complete Section I if an illustration is used and a copy was left with the client. Complete Section II in full if no illustration is used or if policy is applied for other than as illustrated. Section I – Illustration Presented and Copy Left with Client

I have provided the client with a copy of the illustration as applied for. A signed copy is being provided with the application.

_________________________________________ __________________________________ Signature of Agent Date

Section II – No Illustration Presented

I have applied for life insurance coverage through EquiTrust Life Insurance Company. As a part of that application for insurance coverage, I acknowledge no illustration conforming to the policy applied for was provided. I further acknowledge and understand an illustration conforming to the policy as issued will be provided to me no later than at the time the policy is delivered.

_________________________________________ _________________________________ Signature of Applicant/Owner Signature of Agent _________________________________________ _________________________________ Print Name of Applicant Agent Number _________________________________________ _________________________________ Date Date

ILLUSTRATION ACKNOWLEDGEMENT

ETL-ILLCERT (02-10)


ET-PRI-4905 (01-12)

This notice is required by law. It explains our information practices. Our practices apply to all current, former and future customers. Information We Collect: In order to help us serve your financial needs and to comply with legal and regulatory requirements, we collect certain information about you. This information varies depending on the products or services you request, but may include: • Information we receive from you on your application or other forms (such as name, address, social security number and

financial and health information), including information you provide via the Internet by completing on-line forms; • Information you allow us to collect (such as health information for underwriting purposes) or information we are

authorized or required by law to collect (such as your taxpayer ID number); • Information about your transactions with us, our affiliates, or others (such as your payment history or account balances); • Information we receive from a consumer reporting agency (such as an investigative consumer report, including credit

relationships and history); and • Information we receive from public records (such as your driving record). Personal information that has been collected about you may be retained both in our records and in your agent’s files. Reports prepared by an insurance-support organization may be retained by the insurance support organization and disclosed to other persons. To the extent provided by law, you have the right to access and correct the information we have collected about you. You are also entitled to certain information regarding disclosures of medical information we may have made. To exercise these rights, provide a written request to the address below, which includes your complete name, address, date of birth, type(s) of policy(ies) held or applied for and all policy numbers issued to you by us. The Security of Your Information: We maintain physical, electronic, and procedural safeguards that comply with state and federal regulations to guard your personal information. Our internal procedures limit access to customer information, and those individuals permitted access are required to protect customer information and to keep it confidential. Information We Share: We may share your information with our affiliates to assist us in providing service for your products or account. This may include sharing information with our affiliates about your account history or experience with us; however, our affiliates do not use such information for marketing purposes. We may also share some of the information we obtain about you with certain business partners, such as:

• Sharing information with companies that service your accounts, or that perform services on our behalf, • Sharing information with companies with whom we have a joint marketing agreement. A joint marketing agreement is

one where another financial institution offers a product or service jointly with us. We require our business partners to protect customers’ personal information and to limit their use of information shared to the purpose for which it was shared. We may also disclose information to non-affiliated third parties as permitted or required by law, including in response to a subpoena, to prevent fraud, to comply with inquiries from government agencies or other regulators, or in order to process a transaction you request or authorize. We do not share medical information except when needed to service your policies, accounts, claims or contracts; when laws protecting your privacy permit it, or when you consent. Medical information and information obtained from a consumer reporting agency or motor vehicle reports is not used for marketing purposes. This notice is being provided on behalf of EquiTrust Life Insurance Company. Receipt of this notice does not mean your application has been accepted. We may change our privacy practices at times. We will give you a revised notice when required by law. Mail inquiries to: EquiTrust Life Insurance Company, Customer Privacy, 7100 Westown Pkwy, Suite 200, West Des Moines, IA 50266-2521

EQUITRUST LIFE INSURANCE COMPANY PRIVACY NOTICE

11/06

National Association of Insurance Commissioners

2301 McGee St

Suite 800

Kansas City, MO 64108-2604

(816) 842-3600

© 1997, 2007 National Association of Insurance

Commissioners

Prepared by the National Association of Insurance Commissioners

The National Association of Insurance Commissioners is an association of state insurance

regulatory officials. This association helps the various insurance departments to coordinate

insurance laws for the benefit of all consumers.

This guide does not endorse any company or policy.

Reprinted by...

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1©1997, 2007 National Association of Insurance Commissioners

Important Things to Consider

1. Review your own insurance needs and circumstances.Choose the kind of policy that has benefits that most closelyfit your needs. Ask an agent or company to help you.

2. Be sure that you can handle premium payments. Can youafford the initial premium? If the premium increases later andyou still need insurance, can you still afford it?

3. Don’t sign an insurance application until you review itcarefully to be sure all the answers are complete andaccurate.

4. Don’t buy life insurance unless you intend to stick with your plan. It may be very costly ifyou quit during the early years of the policy.

5. Don’t drop one policy and buy another without a thorough study of the new policy and theone you have now. Replacing your insurance mmaayy bbee ccoossttllyy..

6. Read your policy carefully. Ask your agent or company about anything that is not clear toyou.

7. Review your life insurance program with your agent or company every few years to keep upwith changes in your income and your needs.

Buying Life Insurance

When you buy life insurance, you want coverage that fits your needs.

First, decide how much you need—and for how long—and what you can afford to pay. Keep inmind the major reason you buy life insurance is to cover the financial effects of unexpected oruntimely death. Life insurance also can be one of many ways you plan for the future.

Next, learn what kinds of policies will meet your needs and pick the one that best suits you.

Then, choose the combination of policy premium and benefits that emphasizes protection incase of early death, or benefits in case of long life, or a combination of both.

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• Find a Policy That Meets Your Needs and Fits Your Budget• Decide How Much Insurance You Need• Make Informed Decisions When You Buy a Policy

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2 ©1997, 2007 National Association of Insurance Commissioners

It makes good sense to ask a life insurance agent or company to help you. An agent can helpyou review your insurance needs and give you information about the available policies. If onekind of policy doesn’t seem to fit your needs, ask about others.

This guide provides only basic information. You can get more facts from a life insurance agentor company or from your public library.

What About the Policy You Have Now?

If you are thinking about dropping a life insurance policy, here are some things you shouldconsider:

• If you decide to replace your policy, don’t cancel your old policy until you have received the new one. You then have a minimum period to review your new policy and decide if it is what you wanted.

• It may be costly to replace a policy. Much of what you paid in the early years of the policy you have now, paid for the company’s cost of selling and issuing the policy. You may pay this type of cost again if you buy a new policy.

• Ask your tax advisor if dropping your policy could affect your income taxes.• If you are older or your health has changed, premiums for the new policy will often be

higher. You will not be able to buy a new policy if you are not insurable.• You may have valuable rights and benefits in the policy you now have that are not in the

new one.• If the policy you have now no longer meets your needs, you may not have to replace it.

You might be able to change your policy or add to it to get the coverage or benefits you now want.

• At least in the beginning, a policy may pay no benefits for some causes of death covered in the policy you have now.

In all cases, if you are thinking of buying a new policy, check with the agent or company thatissued you the one you have now. When you bought your old policy, you may have seen anillustration of the benefits of your policy. Before replacing your policy, ask your agent orcompany for an updated illustration. Check to see how the policy has performed and whatyou might expect in the future, based on the amounts the company is paying now.

How Much Do You Need?

Here are some questions to ask yourself:

• How much of the family income do I provide? If I were to die early, how would my survivors, especially my children, get by? Does anyone else depend on me financially, such as a parent, grandparent, brother or sister?

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3© 1997, 2007 National Association of Insurance Commissioners

• Do I have children for whom I’d like to set aside money to finish their education in the event of my death?

• How will my family pay final expenses and repay debts after my death?• Do I have family members or organizations to whom I would like to leave money?• Will there be estate taxes to pay after my death?• How will inflation affect future needs?

As you figure out what you have to meet these needs, count the life insurance you have now,including any group insurance where you work or veteran’s insurance. Don’t forget SocialSecurity and pension plan survivor’s benefits. Add other assets you have: savings,investments, real estate and personal property. Which assets would your family sell or cash into pay expenses after your death?

What is the Right Kind of Life Insurance?

All policies are not the same. Some give coverage for yourlifetime and others cover you for a specific number of years.Some build up ccaasshh vvaalluueess and others do not. Some policiescombine different kinds of insurance, and others let youchange from one kind of insurance to another. Some policiesmay offer other benefits while you are still living. Your choiceshould be based on your needs and what you can afford.

There are two basic types of life insurance: tteerrmm iinnssuurraanncceeand ccaasshh vvaalluuee iinnssuurraannccee. Term insurance generally haslower premiums in the early years, but does not build up cashvalues that you can use in the future. You may combine cashvalue life insurance with term insurance for the period ofyour greatest need for life insurance to replace income.

TTeerrmm IInnssuurraannccee covers you for a term of one or more years. Itpays a death benefit only if you die in that term. Terminsurance generally offers the largest insurance protection foryour premium dollar. It generally does not build up cash value.

You can renew most term insurance policies for one or more terms even if your health haschanged. Each time you renew the policy for a new term, premiums may be higher. Ask whatthe premiums will be if you continue to renew the policy. Also ask if you will lose the right torenew the policy at some age. For a higher premium, some companies will give you the rightto keep the policy in force for a guaranteed period at the same price each year. At the end ofthat time you may need to pass a physical examination to continue coverage, and premiumsmay increase.

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4 ©1997, 2007 National Association of Insurance Commissioners

You may be able to trade many term insurance policies for a cash value policy during aconversion period—even if you are not in good health. Premiums for the new policy will behigher than you have been paying for the term insurance.

CCaasshh VVaalluuee LLiiffee IInnssuurraannccee is a type of insurance where the premiums charged are higher atthe beginning than they would be for the same amount of term insurance. The part of thepremium that is not used for the cost of insurance is invested by the company and builds upa cash value that may be used in a variety of ways. You may borrow against a policy’s cashvalue by taking a policy loan. If you don’t pay back the loan and the interest on it, the amountyou owe will be subtracted from the benefits when you die, or from the cash value if you stoppaying premiums and take out the remaining cash value. You can also use your cash value tokeep insurance protection for a limited time or to buy a reduced amount without having topay more premiums. You also can use the cash value to increase your income in retirementor to help pay for needs such as a child’s tuition without canceling the policy. However, tobuild up this cash value, you must pay higher premiums in the earlier years of the policy. Cashvalue life insurance may be one of several types; whole life, universal life and variable life areall types of cash value insurance.

WWhhoollee LLiiffee IInnssuurraannccee covers you for as long as you live if your premiums are paid. Yougenerally pay the same amount in premiums for as long as you live. When you first take outthe policy, premiums can be several times higher than you would pay initially for the sameamount of term insurance. But they are smaller than the premiums you would eventually payif you were to keep renewing a term policy until your later years.

Some whole life policies let you pay premiums for a shorter period such as 20 years, or untilage 65. Premiums for these policies are higher since the premium payments are made duringa shorter period.

UUnniivveerrssaall LLiiffee IInnssuurraannccee is a kind of flexible policy that lets you vary your premium payments.You can also adjust the face amount of your coverage. Increases may require proof that youqualify for the new death benefit. The premiums you pay (less expense charges) go into apolicy account that earns interest. Charges are deducted from the account. If your yearlypremium payment plus the interest your account earns is less than the charges, your accountvalue will become lower. If it keeps dropping, eventually your coverage will end. To preventthat, you may need to start making premium payments, or increase your premium payments,or lower your death benefits. Even if there is enough in your account to pay the premiums,continuing to pay premiums yourself means that you build up more cash value.

VVaarriiaabbllee LLiiffee IInnssuurraannccee is a kind of insurance where the death benefits and cash valuesdepend on the investment performance of one or more separate accounts, which may beinvested in mutual funds or other investments allowed under the policy. Be sure to get theprospectus from the company when buying this kind of policy and STUDY IT CAREFULLY. Youwill have higher death benefits and cash value if the underlying investments do well. Yourbenefits and cash value will be lower or may disappear if the investments you chose didn’t doas well as you expected. You may pay an extra premium for a guaranteed death benefit.

Find

ing

a G

ood

Val

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Life

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5© 1997, 2007 National Association of Insurance Commissioners

Life Insurance Illustrations

You may be thinking of buying a policy where cash values, death benefits, dividends orpremiums may vary based on events or situations the company does not guarantee (such asinterest rates). If so, you may get an illustration from the agent or company that helps explainhow the policy works. The illustration will show how the benefits that are not guaranteed willchange as interest rates and other factors change. The illustration will show you what thecompany guarantees. It will also show you what could happen in the future. Remember thatnobody knows what will happen in the future. You should be ready to adjust your financialplans if the cash value doesn’t increase as quickly as shown in the illustration. You will beasked to sign a statement that says you understand that some of the numbers in theillustration are not guaranteed.

Finding a Good Value in Life Insurance

After you have decided which kind of life insurance is bestfor you, compare similar policies from differentcompanies to find which one is likely to give you the bestvalue for your money. A simple comparison of thepremiums is not enough. There are other things toconsider. For example:

• Do premiums or benefits vary from year to year?• How much do the benefits build up in the policy?• What part of the premiums or benefits is not

guaranteed?• What is the effect of interest on money paid and

received at different times on the policy?

Remember that no one company offers the lowest cost at all ages for all kinds and amounts ofinsurance. You should also consider other factors:

• How quickly does the cash value grow? Some policies have low cash values in the early years that build quickly later on. Other policies have a more level cash value build-up. A year-by-year display of values and benefits can be very helpful. (The agent or company willgive you a policy summary or an illustration that will show benefits and premiums for selected years.)

• Are there special policy features that particularly suit your needs?• How are nonguaranteed values calculated? For example, interest rates are important in

determining policy returns. In some companies increases reflect the average interest earnings on all of that company’s policies regardless of when issued. In others, the returnfor policies issued in a recent year, or a group of years, reflects the interest earnings on that group of policies; in this case, amounts paid are likely to change more rapidly when interest rates change.

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National Association of Insurance Commissioners

2301 McGee St

Suite 800

Kansas City, MO 64108-2604

(816) 842-3600

© 1997, 2007 National Association of Insurance

Commissioners

Are you thinking about buying a new life insurance policy and discontinuing or changing an existing one? If you are, your decision could be a good one – or a mistake. You will not know for sure unless you make a careful comparison of your existing benefits and the proposed benefits.

Make sure you understand the facts. You should ask the company or agent that sold you your existing policy to give you information about it. You are urged not to take action to terminate, assign or alter your existing life insurance coverage until you have been issued the new policy, examined it and found it acceptable.

Hear both sides before you decide. This way you can be sure you are making a decision that is in your best interest.

IF YOU SHOULD FAIL TO QUALIFY FOR THE LIFE INSURANCE FOR WHICH YOU HAVE APPLIED, YOU MAY FIND YOURSELF UNABLE TO PURCHASE OTHER LIFE INSURANCE OR ABLE TO PURCHASE IT ONLY AT SUBSTANTIALLY HIGHER RATES.

We are required by law to notify your existing company that you may be replacing their policy.

Applicant’s Signature Date Producer’s Signature Date

NOTICE TO APPLICANTS REGARDING REPLACEMENT OF YOUR LIFE INSURANCE POLICY

TENNESSEE

EquiTrust Life Insurance Company • PO Box 14500 • Des Moines, Iowa 50306-3500 • (866) 598-3692

436-176TN (07-98) ET-RPL-4900TN (9-05)

EquiTrust Life Insurance Company • P.O. Box 14500 • Des Moines, IA 50306-3500 866-598-3692

SECTION 1035 TAX FREE EXCHANGES A Section 1035 Tax-Free Exchange eliminates taxation to the contract owner when their intent is to exchange one insurance contract for another better suited to their needs. The exchange of funds occurs from one company to another. The check must be payable to the company that is either issuing a new contract or accepting the funds into an existing contract. If the check is made payable to the individual and endorsed over to the new company, a 1035 Exchange is not accomplished and the contract owner will have to pay taxes on the gain in the old contract.

The following types of exchanges are permitted under Section 1035:

1. A LIFE insurance policy can be exchanged for another LIFE insurance policy, ENDOWMENT policy or NONQUALIFIED ANNUITY.

2. An ENDOWMENT policy can be exchanged for another ENDOWMENT policy or NONQUALIFIED ANNUITY. An Endowment policy cannot be exchanged for a life insurance policy.

3. A NONQUALIFIED ANNUITY can be exchanged for another NONQUALIFIED ANNUITY.

An additional requirement is that the Annuitant or Insured on the new contract must be the same as that on the old contract. Two or more existing insurance contracts may be exchanged for one new contract, or vice versa. Or, a contract may be exchanged and the funds from the contract may be placed in a contract previously issued.

Even though a nontaxable event occurs, the Internal Revenue Service requires that a 1099R be issued for informational purposes on an exchange (none is required if the exchange is within the same company).

In order to affect a true tax-free exchange, the existing contract cannot have a loan outstanding. The loan must be repaid prior to the exchange. If not, the loan is taxed as income received to the extent of any gain in the contract. Taxation can also occur if any of the proceeds of the exchange are used as advance premiums on the new contract. The amount of money placed in advance premiums will be taxed as income to the extent of any gain in the contract. Also, any cash refunded with an exchange is taxable to the extent of the gain in the contract exchanged.

The following procedures should be followed when handling a 1035 Exchange for your client:

1. The contract owner assigns the existing contract to us using the proper 1035 Exchange/Absolute Assignment form ET-TRN/1035-4902 for annuity policies and ETL-1035/TRN for life policies.

2. The agent completes the Application for the appropriate contract, or indicates which existing contract should receive the 1035 proceeds. (Please enter the number of such an existing contract on the last line of the 1035 Exchange/Absolute Assignment form.) Keep in mind that all insurance contracts contain a provision that the Company can withhold surrender proceeds for a period of six months.

3. The agent sends us the completed Application, 1035 Exchange/Absolute Assignment form, old contract and appropriate replacement forms, if required.

4. After all issuing requirements are met we send the old contract, 1035 Exchange/Absolute Assignment form and surrender request to the old company to have the proceeds transferred directly to us to be applied to the new contract. If the 1035 exchange will be into an existing contract, the 1035 Exchange/Absolute Assignment form and surrender request will be sent to the old company within a reasonable time after they are received.

5. The old company sends the surrender check to the new company together with cost basis information on the old contract being exchanged.

6. The surrender value of the old contract is applied to the new contract (or existing contract) and the cost basis information from the old contract is added to the new contract record. If the new contract is later surrendered, the contract owner will be taxed on the gain carried forward from the old contract as well as the gain on the new contract.

7. If this is an internal exchange (one of our contracts for a new contract) we will not require an assignment. Indicate on the Application that this is an exchange and complete a Policy Service Request form for the old contract, making the notation the funds are to be applied to the new contract when issued, or another existing contract. If the loan is outstanding on the existing contract, we prepare a notification of taxation and withholding requirement that must be signed and returned to us by the contact owner. Upon receipt of this signed form, we will process the exchange.

8. Insurance department replacement regulations and company replacement commission rules apply to all Section 1035 Exchanges. Caution should be used before suggesting an exchange of an existing contract for a new one as it is not always in the best interests of the contractholder to replace existing insurance.

9. Once the contract is issued it is sent to the Agent for prompt delivery to the contract owner(s).

1035 EXCHANGE INSTRUCTIONS

ET-436-830 (09-13)

EXISTING COMPANY

PHONE NUMBER (IMPORTANT)

EXISTING COMPANY STREET ADDRESS – OVERNIGHT MAIL ONLY ‐ NO PO BOXES CITY STATE ZIP

EXISTING CONTRACT/POLICY NUMBER BEING EXCH/TRANSFERRED EXISTING PLAN TYPE (EX. ANNUITY, MUTUAL FUND, CD, ETC.) EXPECTED AMT. OF EXCH/TRANS

INSURED’S NAME INSURED’S SOCIAL SECURITY NUMBER

OWNER’S NAME (IF OTHER THAN INSURED) OWNER’S SOCIAL SECURITY NUMBER

We will NOT accept any 1035 Exchanges with an outstanding loan.

REQUEST FOR 1035 EXCHANGE OF LIFE INSURANCE POLICIES

NON-QUALIFIED TRANSFER REQUEST

____ Full 1035 Exchange I hereby make a complete and absolute assignment and transfer all rights, titles, and interests of every nature and character in and to the above policy to the Company in an exchange intended to qualify under Section 1035 of the Internal Revenue Code. Additionally, by signing this form, I acknowledge that this exchange qualifies under Section 1035 of the Internal Revenue Code as a “like-to-like” exchange. Upon receipt, the Company is directed to surrender all of my policy 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 policy. 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.

I wish to liquidate and transfer the: ____ Full Value ____ Partial Value of $________________ or _______% The Company will apply all such funds received to a life policy issued to me. I understand that the Company assumes no responsibility for tax treatment of this matter and I shall be responsible for payment of all federal, state, and local taxes incurred with respect to the liquidation of such account. I acknowledge that the earnings credited under the policy will begin to accrue when the Company receives these proceeds and all other necessary paperwork in good order.

PLEASE TRANSFER THESE FUNDS ____immediately or ____ on a specific date ___/___/____

Return of Contract/Policy (Please choose if you are transferring the full value of your current contract/policy) ____ I certify that I cannot find my contract/policy. ____ The contract/policy is attached.

I UNDERSTAND THAT THE FIRST PREMIUM MUST BE PAID NO LATER THAN THE TIME THE POLICY APPLIED FOR IS ISSUED AND THAT THE CASH VALUE OF THE ASSIGNED POLICY SHALL NOT BE CONSIDERED PART OF THE PREMIUM UNTIL THE CASH SURRENDER VALUE IS ACTUALLY RECEIVED BY THE COMPANY. I FURTHER UNDERSTAND THAT NO INSURANCE COMES INTO FORCE AS A RESULT OF THIS ASSIGNMENT.

SIGNATURES AND AUTHORIZATIONS Please make check(s) payable to: EquiTrust Life Insurance Company.

Send to: EquiTrust Life Insurance Company Attn: New Business, 7100 Westown Pkwy Suite 200, West Des Moines, IA 50266-2521

I understand that the Company is providing this form for my convenience and makes no representations concerning my tax treatment. I agree to execute any additional documents required to complete this transaction.

____________________________________________ ___________________________________________ Signature of Owner (Note: A signature guarantee may be required) Signature of Joint Owner (if applicable)

____________________________________________________ Place Signature Guarantee Stamp here: Date

____________________________________________________ _____________________________________________________ Signature Guarantee by: Name of Bank/Firm Signature of Officer and Title

ACCEPTANCE FOR TRANSFER/1035 EXCHANGE (Home Office Use Only) The Company requests this liquidation and transfer of the assets listed above. By its signature below, the Company represents that the above described receiving Policy is or is intended to be a Policy of the type indicated and that the Company will accept the Section 1035 Exchange/Transfer on behalf of the person(s) named on this form. Please provide us with a report of the pre-and post-TEFRA cost basis in the current policy, if applicable. ________________________________________________ ______________________________________________ Authorized Signature Date __________________________________________________ __ __________________________________________________ Title New Policy Number

LIFE 1035 EXCHANGE/TRANSFER FORM


ETL-1035/TRN (07-12)

Please refer to the following chart when requesting a 1035 Exchange or Non-Qualified Transfer. Keep this information in mind when requesting any of the following as to the tax consequences that could affect your client. This chart is only a guideline. Neither EquiTrust Life Insurance Company nor any officer, employee, agent, not any person acting on behalf of EquiTrust Life Insurance Company warrants or represents the income tax consequences of this transaction.

From To Type of Transaction

Comments or Additional Information Needed

Life Insurance Policies


1035 Exchange

This transaction will not be reported as a taxable event. This will be a 1035 Exchange. Note: This must be a “like-to-like” transaction in that the owner, annuitant or insured must be the same on both accounts.

Savings, CD, Mutual Fund

Account or the Value of Stocks or

Bonds


Non-Qualified Transfer

This transaction will not be reported as a taxable event.

Non-Qualified Annuity


Non-Qualified Transfer

This transaction may be reported as a taxable event.

Even though a nontaxable event occurs, the Internal Revenue Service require that a Form 1099R be issued for informational purposes on an exchange (none is required if the exchange is within the same company). In order to affect a true tax-free exchange, the existing contract cannot have a loan outstanding. The loan must be repaid prior to the exchange. If not, the loan is taxed as income received to the extent of any gain in the contract. Taxation can also occur if any of the proceeds of the exchange are used as advance premiums on the new contract. The amount of money placed in advance premiums will be taxed as income to the extent of any gain in the contract. Also, any cash refunded with an exchange is taxable to the event of the gain in the contract exchanged.

Mailing Instructions

Please send the completed application and all transfer paperwork to the following address:

EquiTrust Life Insurance Company P.O. Box 14500 Des Moines, IA 50306-3500

or overnight mail to:

EquiTrust Life Insurance Company 7100 Westown Pkwy Suite 200 West Des Moines, IA 50266-2521


1035 EXCHANGE/NON-QUALIFIED TRANSFER INFORMATION

ETL-1035/TRN (07-12)

Payment of the sum of: $__________________________________________________ Amount of Premium

From: ________________________________________________________________ Client’s Full Name

To be applied for: _______________________________________________________ Indicate policy type/number or application date

is acknowledged by the undersigned. ______________________________________ Date ______________________________________ ____________________________________ Agent Signature Agent Number NOTE: Signed delivery receipts may be mailed to the home office or faxed to 515-226-5103.

EquiTrust Life Insurance Company • P.O. Box 14500 • Des Moines, IA 50306-3500 Phone 866-598-3692 • Fax 515-226-5103

CLIENT RECEIPT

ETL-RECPT (04-13)