DEPARTMENT OF LABOR AND REGULATION

1. (Company) (Date)

   Cash Surrender

   1. With respect to the above numbered policy/contract I (we) wish to:

   obtain the entire cash surrender or account value which will be accepted, irrevocably, in full payment of all claims under the policy or contract, or

   obtain the entire cash surrender value of rider or paid up addition only, or

   obtain a partial withdrawal from the policy/contract only of $______________, or

   obtain a partial withdrawal from the rider or paid up addition only of $_____________.

   2. The policy/contract is: submitted herewith, or I (we) certify that the original policy/contract, any duplicates, certificates, or riders have been lost or destroyed.

   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 CASH SURRENDER

Chapter 20:06:08

APPENDIX B

SEE: § 20:06:08:42(2)

Uniform Transaction Form for Cash Surrender:

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.