DEPARTMENT OF LABOR AND REGULATION

1. (Company) (Date)

   Policy Loan

   1. It is understood and agreed that, I (we), the undersigned, assign the policy to the company as security for the repayment of a policy loan (andanyunpaidinterestthereon), and apply for a loan in such amount as will retire any previous loans, pay all interest as provided in the policy, and provide the following amount:

   Maximum loan available including any dividend values, or

   Maximum loan available excluding any dividend values

   2. Loan repayment method:

   Send repayment reminders:

   Monthly Quarterly Annually

   Apply future dividends to pay any premium due with the remaining applied to the loan, or

   Apply future dividends to the loan.

   3. I (we) certify that no bankruptcy proceeding, attachment, other lien, or claim is now pending against the owner(s) of the policy/contract. ______

   Initial

   We (thecompany) are required to inform you of and give you an opportunity to make a tax withholding election. The provisions apply to qualified and non-qualified deferred compensation plans, annuities, pension plans, IRA distributions and gains realized from life insurance and endowment policy distributions. If you elect not to have withholding apply to your payment, or if you do not have enough federal income tax withheld, you may be responsible for payment of estimated tax. You may also incur penalties under the estimated tax rules if your withholding and estimated tax payments are not sufficient. You may wish to consult a tax advisor.

   I elect not to have federal income tax withheld from the taxable portion of my distribution check.

   I elect to have federal income tax withheld from the taxable portion of my distribution check, reducing the indicated amount by the amount withheld.

   I certify that:

   1. The number shown on this form is my correct taxpayer identification number, and

   2. I am not subject to any backup withholding, and

   3. I am a US person (includingUSresidentalien).

   _____________________________________ ____________ _____________________________________ ____________

2. (PolicyOwnerSignature) (Date) (JointPolicyOwnerSignature) (Date)

   _____________________________________ ____________ _____________________________________ ____________

3. (IrrevocableBeneficiaryorAssignee) (Date) (IrrevocableBeneficiaryorAssignee) (Date)

DIVISION OF INSURANCE

UNIFORM FORM FOR LIFE INSURANCE OR ANNUITY MAXIMUM POLICY LOAN

Chapter 20:06:08

APPENDIX A

SEE: § 20:06:08:42(1)

Uniform Transaction Form for Maximum Policy Loan:

Name of Insured/Annuitant:

Social Security or Taxpayer ID No:

Policy/Contract No:

Joint Insured/Annuitant:

Social Security or Taxpayer ID No:

Daytime Phone No:

Policy Owner (ifdifferentthaninsured):

Social Security or Taxpayer ID No:

Street Address:

Joint Policy Owner (ifdifferentthaninsured):

Social Security or Taxpayer ID No:

City, State, and Zip Code:

I own the following: Life Insurance Policy Endowment Annuity Contract

This policy was issued by: _____________________ on __________.

Source: 29 SDR 48, effective October 10, 2002; 39 SDR 55, effective October 4, 2012.