Western National Insurance – Fill Out and Use

ABSOLUTE

I/We hereby assign, transfer and convey all rights, title and interest in and to the subject contract to

ASSIGNMENT

1.

.

New Owner (Please print)

New Co-Owner, if any (Please print)

(Transfer/Change of

.

Ownership)

Address of New Owner

Address of New Co-Owner

.

New Owner’s Social Security Number

Owner’s Date of Birth

New Co-Owner’s Social Security Number Co-Owner’s Date of Birth

PLEASE ATTACH

OR

I certify that the original customer copy of my policy/certificate has been lost or destroyed. After due search and to the

ANNUITY

CONTRACT

best of my knowledge, it is not in the possession or control of any other person. I understand that a duplicate policy

will be issued, endorsed and forwarded to the new Owner.

BENEFICIARY DESIGNATION FOR NEW OWNER

I/We revoke existing designations and make the following Primary and Contingent Beneficiary designations as listed

below. If the beneficiary is a Trust, please include the Name AND Date of the Trust.

If you wish to change the Annuitant’s beneficiary or Joint Owner’s, please complete Section 2 on the reverse side.

The New Owner’s Beneficiary

Primary

Beneficiary:

.

Please Print Name, Relationship and Age of Beneficiary

.

Address, City, State and Zip Code of Beneficiary

Contingent

Beneficiary:

.

Please Print Name, Relationship and Age of Beneficiary

.

Address, City, State and Zip Code of Beneficiary

Unless otherwise directed, proceeds payable will be divided equally among the surviving beneficiaries. The Company

shall not be liable for proceeds paid to a Trustee nor be required to determine that a trust is in effect. To determine the

existence or identity of the members of a designated class of beneficiaries, The Company may rely on such

documentation as it deems sufficient. If not stated otherwise, the right to change a beneficiary is reserved to the Owner.

TAXPAYER ID NUMBER

TAX IDENTIFICATION NUMBER OF PRESENT OWNER: This section must be completed by the present

owner of the annuity. Failure to do so may delay your request.

PRESENT OWNER’S TAX ID / Social Security Number

NOTE: FOR ANNUITIES ISSUED AFTER APRIL 21, 1987, ANY GAIN AT TIME OF

TRANSFER WILL BE TAX REPORTED. IRS FORM 1099 WILL BE ISSUED AT YEAR END.

.

Date

Signature Present Owner

Signature Present Co-Owner, if any

.

Date

Signature New Owner

Signature New Co-Owner, if any

.

Signature of Irrevocable Beneficiary, if any

NOTE: SIGNATURE(S) MUST BE NOTARIZED OR WITNESSED BY TWO ADULTS WHO ARE NOT NEW OWNER(S).

.

Notary Public

Witness Signature

Witness Signature

ACKNOWLEDGMENT

When acknowledged by Company endorsement, the change shall take effect on the date this form was signed by Owner(s),

but without prejudice to The Company on account of payment made or action taken before the date of acknowledgment.

(For Home Office

.

Use Only)

Date of Acknowledgment

Authorized Signature

WNL 100 (6/09)

Page 1 of 2

BENEFICIARY

I/We revoke existing designations and subject to any existing assignment, make the following Primary and Contingent

CHANGE

2.

Beneficiary designations as listed below:

**If the Beneficiary is being changed to a TRUST, please include the Name AND Date of the TRUST**

The Annuitant’s Beneficiary

Primary Beneficiary:

.

Please Print Name, Relationship and Age of Beneficiary

.

Address, City, State and Zip Code of Beneficiary

Contingent Beneficiary:

.

Please Print Name, Relationship and Age of Beneficiary

.

Address, City, State and Zip Code of Beneficiary

The Joint Owner’s Beneficiary

Primary Beneficiary:

.

Please Print Name, Relationship and Age of Beneficiary

.

Address, City, State and Zip Code of Beneficiary

Contingent Beneficiary:

.

Please Print Name, Relationship and Age of Beneficiary

.

Address, City, State and Zip Code of Beneficiary

The Owner’s Beneficiary

Primary Beneficiary:

.

Please Print Name, Relationship and Age of Beneficiary

.

Address, City, State and Zip Code of Beneficiary

Contingent Beneficiary:

.

Please Print Name, Relationship and Age of Beneficiary

.

Address, City, State and Zip Code of Beneficiary

Unless otherwise directed, proceeds payable will be divided equally among the surviving beneficiaries. The Company

shall not be liable for proceeds paid to a Trustee nor be required to determine that a trust is in effect. To determine the

existence or identity of the members of a designated class of beneficiaries, The Company may rely on such

documentation as it deems sufficient. If not stated otherwise, the right to change a beneficiary is reserved to the Owner.

ADDRESS

Previous

Current

CHANGE

3.

Address:

.

Address:

.

.

.

.

.

NAME

Annuitant

Owner

CHANGE

4.

From:

To:

.

ATTACH

Reason:

Marriage

Divorce

Other (explain below)

DOCUMENTATION

.

DUPLICATE

I/We certify the subject contract has been lost or destroyed and request that a duplicate be issued. If a duplicate is issued,

CONTRACT

the original shall be null and void. The contract has not been sold, assigned or pledged to any person or organization.

REQUEST

5.

WITNESSED

ALL REQUESTS OR CHANGES REQUIRE WITNESSED SIGNATURE(S)

SIGNATURE(S)

6.

.

(Complete This Section

Date

Witness Signature

Owner Signature

.

For All Requests

Date

Witness Signature

Co-Owner Signature

EXCEPT

.

Ownership Changes.)

Date

Witness Signature

Signature of Irrevocable Beneficiary, if any

.

ACKNOWLEDGMENT

When acknowledged by Company endorsement, the change shall take effect on the date this form was signed by Owner(s),

but without prejudice to The Company on account of payment made or action taken before the date of acknowledgment.

(For Home Office

.

Use Only)

Date of Acknowledgment

Authorized Signature

WNL 100 (6/09)

Page 2 of 2