Symetra Life Insurance Login – ICC21_RA1 Page[ 1 of 7] [RSA-0098 5/21] Symetra Life Insurance Company [777 108th Avenue NE, Suite 1200 | Bellevue, WA 98004-5135 Mail to: PO Box 305154 | Nashville, TN 37230-5154 Accommodation: 100 Centerview Drive, Suite 100 | Nashville, TN 37214-3439 Phone 1-800-796-3872] Individual Application for Single Premium Annuity [Index Linked Deferred Annuity] /TIN Cell Phone Other Phone Email Citizenship Name of Joint Owner Residential Address Postal Address DINth M Phone Other Phone Email Owner Nationality Name Annuitant Residential Address Postal Address Gender M F Date of Birth SSN/TIN Cell Phone Email Nationality Relationship to Other Owner Phone Name Annuitant Joint Residential Address Postal Address Gender M F Date of Birth SSN/TIN Mobile Phone of another owner
ICC21_RA1 Page[ 2 of 7] [Beneficiary/Legacy Accounts Only] [Relationship of Deceased to Owner at Date of Death, was the balance at the end of the previous year taken from the existing account? YES NO CORRECT PROPERTY TITLE IN OWNER] PRINCIPAL USER Contingent Beneficiary Name Address Relationship SSN/TIN Cell Phone Other Phone Date of Birth/Citizenship [Nationality] Email Beneficiary % Contingent Beneficiary Address Mobile/Other [ Nationality] E -Email of Beneficiary % Name of Primary Contingent Beneficiary Name Link SSN/TIN Mobile Phone Other Phone Date of Birth/Financial [Citizenship] Beneficiary Email % Beneficiary Name of Primary Contingent Link SSN/TIN Cell Phone Date ] Beneficiary Email Other Address Relationship SSN/TIN Cell Phone Other Phone Date of Birth/Financial [Citizenship] Email Beneficiary % Payment Amount [Rot IRA Taxable Contribution in First Year: Year __________ ]
Symetra Life Insurance Login
ICC21_RA1 Page [3 of 7] Initial Supplement Add your payment to purchase the options below. The minimum distribution to any account is [$2,000]. Your initial funds will be automatically distributed based on the selections made below on the first available distribution date after the contract date. [If you are purchasing a product with an index counter option that has a charge, you acknowledge and understand that these index accounts have a charge that reduces the value of the contract and is not guaranteed to exceed the index counter option. Billing.] List your allowance (total percentage only; total allowance must equal 100%): Account Option: Starting Allowance(s): [Allowance]
A Bit About Project Parachute
ICC21_RA1 Page[ 4 of 7] [Rebalancing Authorization I/We have read the information about the Rebalancing Option in the prospectus [Annual, ] and wish to choose to rebalance the portion of my contract value specified in the Initial Allocation section. ] [Features [See prospectus or contract for full details. A fee may be charged for this feature.]] ] [Transfer Authorization I/We authorize Symetra to accept and act on telephone instructions from me or anyone listed below regarding the transfer of funds between options in my annuity account. Contract execution or return closing. This authorization remains in effect until Symetra receives written termination from me. Please check all that apply: If no option is selected, we are the owner and joint owner (if applicable) of my insurance manufacturer (on file with Symetra and their staff) listed under Authorized Third Parties. Please write their full name below. Name(s) of Authorized Third Party: _________________________________________________________________________________ Reject telephone instructions from any caller when Symetra cannot determine to the satisfaction of the caller that the caller is authorized to give such instructions. Symetra reserves the right to transmit by telephone, call Symetra at [1-800-SYMETRA (1-800-796-3872)]. All phone transfer calls are recorded. You will be registered. A confirmation of the transfer transaction(s) will be sent. Instructions, if available, may also be provided online if you or your authorized party can log in with certain identifying information, such as a password or personally identifiable information. You should protect your login information because anyone who provides your information has access to the Internet. We cannot verify that you are the person logging into your account and providing instructions or that you are an authorized person. Unless otherwise indicated, this form does not allow others to exercise discretionary authority to transact on your behalf without your prior authorization.]
ICC21_RA1 Page[ 5 of 7] [Electronic Delivery I want to receive updates to the prospectus and other documents related to my contract online by visiting the Symetra website www.symetra.com. I understand that I will be notified that the documents are available on the website by email sent to me. Important information regarding electronic delivery: Documents delivered electronically now include the prospectus and any prospectus supplements. Additional documents may be available for electronic delivery in the future. If Symetra cannot verify the email address or reasonably suspects that the email address is incorrect, electronic delivery will not be activated and paper documents will be sent. You must update your email filters to allow email notifications from Symetra. If emails are returned as undeliverable, electronic delivery will be canceled and documents will be sent by post. There is no cost to you for electronic delivery, even if your ISP charges carrier fees. To view the documents, you must have access to the Internet. Disclosure documents in PDF format; If you don’t have Adobe Acrobat, download it for free at www.adobe.com. Symetra may, without prior notice to you, provide paper documents by mail in lieu of electronic delivery at any time. You may request a hard copy of the information at any time without charge by calling us. For jointly owned contracts, both owners agree to send information to the specified email address. To withdraw your consent, update your email address, or receive a copy of any document by mail, call us at [1-800-796-3872], submit a written notice or the applicable form, or update your shipping options on our website. This consent to receive electronic delivery of discovery documents remains in effect until revoked. E-mail for electronic delivery: ________________________________________________ Notice of documents for electronic delivery is delivered to one e-mail only. The email address provided above will replace the existing email address, if applicable. If no email address is provided here, the email address in the owner section of this application will be used for electronic delivery purposes.]
ICC21_RA1 Page[ 6 of 7] Employer’s Statement and Signature Do you have any life insurance or annuity contracts with this or any other company? Yes (complete all state-specific replacement forms if necessary) No Is this contract intended to replace or replace any life insurance or annuity contract with this or any other company? Yes (if necessary, complete these forms and submit the country-specific replacement form) Company Name Existing Contract Number Company Name Existing Contract Number Company Name Existing Contract Number Company Name Existing Contract Number Available other substitutes. I understand that this annuity is not federally insured. On my own behalf and on behalf of anyone claiming any interest under this agreement, I declare that the statements and answers in this application are full, complete and true to the best of my knowledge and are part of the given annuity agreement. Here. I understand that I am purchasing an annuity contract. I believe this agreement meets my financial needs. I have read and understand the important disclosures below. I received an annuity buyer’s guide for applicable states. I received the current prospectus. [Connecticut residents only: I received an annual CT statement.] [Affidavit W-9: Under penalty of perjury, I certify that the number shown on this form is my correct social security number or tax identification number, I am a U.S. citizen, or another US citizen. individual, and I am not subject to withholding because I have not reported all interest or dividends. Check this box if you have received notice from the IRS that you are subject to withholding. Check this box if you are seeking non-U.S. status and submitting the appropriate withholding certificate (usually a signed IRS Form W-8 or IRS Form 8233) instead of agreeing to this certification. ] FRAUD ALERT: Anyone who makes a false statement on an insurance claim may be guilty of a felony and subject to penalties under state law. I understand that withdrawals from an indexed account before the end of the interest period will not earn indexed interest. Any indexed interest is credited only at the end of each interest term. I understand that I am purchasing a deferred annuity contract linked to a registered index and that the value of this contract may be affected by an external index.