Type Description Form Number Application Packets Application Packets Online Privacy Policy Online Privacy Policy Application Packets EZ Worksheet Packet - paper ticket with access to accelerated underwriting EZ Worksheet Application Packets Application Transmittal Form PLB-3394 Application Packets Informal Transmittal F-LAD-325 Application Packets TeleLife Fax Pre-Application for Term/UL U-664-DC Application Packets Term and Universal Life Application (Includes basic forms - single print) ICC21-400R DC short Application Packets Term and Universal Life Application (Includes supplemental forms - two sided print) ICC21-400R DC packet Application Packets Electronic Policy Delivery Form ADMIN-2494214 Application Packets Indexed Universal Life Application - Initial Allocation of Premiums ICC13-IUL-SUPP Application Packets **Variable Universal Life Application Packet **ICC14-V1APP DC Application Packets **Variable Universal Life Fund Allocations for SOVUL II - MUST ACCOMPANY VUL APP **ICC21-V4FUND SOVULII Application Packets **Variable Universal Life Fund Allocations for PIBA VUL - MUST ACCOMPANY VUL APP **ICC21-V4FUND PIBA VUL Application Packets Aspirations Variable Annuity Application Packet Aspirations VA Pkt DC Application Packets Protective Asset Builder II Annuity Application Packet 10 Year Asset Builder II 10 BGA DC Application Packets Protective Dimensions V Annuity Application Dimensions V Multistate Application Packets Protective Guaranteed Income Indexed Annuity Packet PGIIA Packet DC Application Packets Protective Income Builder with Guaranteed Income Benefit Application Packet Income Builder DC Application Packets Protective ProPayer Income Annuity Application Packet IPD-2110-R1-FR DC AppPack Application Packets Protective Secure Saver Application Packet Secure Saver Packet DC Application Packets Protective Variable Annuity Application Packet (B Series) B Series VA for DC Application Packets Protective Variable Annuity Application Packet (Investors Series) Investors Series Pkt DC Immediate Annuity Forms Immediate Annuity Forms Authorization to Obtain and Disclose Information LAD-1190 Fixed Annuity Forms Fixed Annuity Forms Appendix A Consumer Profile for use with Suitability Form Appendix A Fixed Annuity Forms Appendix B Consumer Profile for use with Suitability Form Appendix B Fixed Annuity Forms Appendix C Consumer Profile for use with Suitability Form Appendix C Fixed Annuity Forms Buyers Guide for Fixed & Equity Indexed Annuity Contracts**ALWAYS GIVE TO APPLICANT** LAD-1189 Fixed Annuity Forms Certificate of Trustee/Contract Owned by Trust P-7019 Fixed Annuity Forms Disability Certification Form 3572-GEN-05 Fixed Annuity Forms Fixed Annuitization Packet LAD-1239 LAD-1126 Fixed Annuity Forms Fund Transfer/Allocation Change Form 3568-GEN-05 Fixed Annuity Forms Instructional Forms List LAD-1204 Fixed Annuity Forms ProSaver Secure II Disclosure Statement LAD-1228 Secure II Disclosure Fixed Annuity Forms ProSaver Secure II Distribution Request Form 3771-GEN-06 Fixed Annuity Forms ProSaver Secure II Non-Financial Change Form 3349-GEN-04 Fixed Annuity Forms ProSaver Secure II Pre-Authorized Checking Agreement 3352-GEN-04 Fixed Annuity Forms ProSaver Secure II Pre-Determined Death Benefit Payout Election Form Pre-Determined Death Benefit Payout Election Form Fixed Annuity Forms ProSaver Secure II Systematic Distribution Form 3361-GEN-04 Fixed Annuity Forms ProSaver Secure R Disclosure Statement LAD-1229 Secure R Disclosure Fixed Annuity Forms Protective Guaranteed Income Indexed Annuity with Guaranteed Income Benefit Election Service Form LAD-1233 PGIIAwGIB Fixed Annuity Forms Protective Income Builder Rising Income Benefit Election LAD-1233-RIB Fixed Annuity Forms Protective Income Builder with Guaranteed Income Benefit Election Service Form LAD-1233 PIBwGIB Fixed Annuity Forms Protective Income Manager Withdrawal Form LAD-1216 Fixed Annuity Forms Required Distribution Election Form for IRA and 403(b) Contracts 3566-GEN-05 Fixed Annuity Forms SecurePay Benefit Election LAD-1233-SEC Fixed Annuity Forms Telephone Transfer Authorization for Annuities LAD-1242 Fixed Annuity Forms Terminal Illness Certification Form 3573-GEN-05 Fixed Annuity Forms Unemployment Certification Form 3574-GEN-04 TeleLife TeleLife TeleLife Application Packet TeleLife DC TeleLife TeleLife Application Packet - VUL TeleLife VUL DC Riders/Benefits Forms Riders/Benefits Forms Rider Worksheet ICC20-403R Riders/Benefits Forms Terminal Illness Accelerated Death Benefit (for use with UL, Term & Alternative to Term) L628-TiD1 Riders/Benefits Forms Child Rider Medical Declarations ICC17-404R Riders/Benefits Forms Child Term Rider Packet CTR Packet Compact Riders/Benefits Forms Disclosure Form for Chronic Illness Accelerated Death Benefit Rider L652-DSC Riders/Benefits Forms Hold Harmless Agreement for Employer Owned Policy with ECR HHA-ECR-Employer Riders/Benefits Forms Hold Harmless Agreement for Trust Owned policy with ECR HHA-ECR-Trust Riders/Benefits Forms Hold Harmless Agreement-One Insured-Multiple Policies with ECR HHA-OneIns-MultECR Riders/Benefits Forms Income Provider Option - Pre-Determined Death Benefit Payout Endorsement ICC18-437R Questionnaires Questionnaires Aviation, Scuba & Racing Questionnaire ICC19-U663 Questionnaires Confidential Financial Statement ICC20-405R Questionnaires Diabetic Questionnaire U-102P-11/83 Questionnaires Drug and Alcohol Use Questionnaire ICC20-603 Questionnaires Foreign National Questionnaire ICC15-601 Questionnaires Foreign Travel and Residence Supplement ICC13-PU646 Questionnaires Military Questionnaire ICC18-PL602 Questionnaires Mountain/Rock Climbing Questionnaire ICC19-U657 Questionnaires Parachute/Sky Diving Questionnaire ICC13-PU601 Questionnaires Tobacco Use Questionnaire (for New Business) ICC12-600 10/12 Conversion & Replacement Forms Conversion & Replacement Forms Assignment/Transfer of Ownership Section 1035 Exchange F-LAD-277 Conversion & Replacement Forms 1035 Exchange Form U-379-R6 Conversion & Replacement Forms Application for Conversion or Exchange ICC13-502 Pkt with TIADB Conversion & Replacement Forms Application for Conversion or Exchange to SOVUL II ICC17-V234 SOVULII Conversion & Replacement Forms Assignment/Transfer of Ownership with Transfer of Outstanding Loan U-640 Conversion & Replacement Forms Dimensions V RightTime Election Form LAD-1198 DIM V Conversion & Replacement Forms SecurePay Income Benefit Election for Dimensions V LAD-1233-DIM V Authorization Forms Authorization Forms Authorization to Obtain and Disclose Information (HIPAA) ICC21-HIPAA3 Authorization Forms Cross Border Sales Certification PLX-425 Authorization Forms Kaiser Permanente Form - All States Kaiser Permanente Authorization Forms Parental Consent for Life Insurance Policies PLX-U398 Premium Payment Premium Payment Pre-Authorized Withdrawal Form PL-104 Premium Payment Conditional Life Receipt PL-CR Premium Payment Employee Payroll Deduction Authorization Form F-LAD-416 (12/08) Premium Payment Pre-Authorized Withdrawal Form F-706-R8 Transfer of Assets and Administrative Annuity Forms Transfer of Assets and Administrative Annuity Forms Annuity Application- FutureSaver IPD-2050 (fillable) Transfer of Assets and Administrative Annuity Forms Annuity Suitability Form LAD-1243R Annuity Suitability Transfer of Assets and Administrative Annuity Forms Assignment of Policy as Collateral Security for Annuities LAD-1235 Transfer of Assets and Administrative Annuity Forms Authorization to Disclose Policy Information LAD-1110 Transfer of Assets and Administrative Annuity Forms Authorization to Disclose Replacement Information LAD-1112 Transfer of Assets and Administrative Annuity Forms Automatic Deposit Agreement Form LAD-1162 Transfer of Assets and Administrative Annuity Forms Automatic Purchase Plan LAD-1128 Transfer of Assets and Administrative Annuity Forms B Series - Payments, Allocations and Transfers LAD-1121 VA II B Series Transfer of Assets and Administrative Annuity Forms B Series II PIM RightTime Election Form LAD-1217-B Transfer of Assets and Administrative Annuity Forms B Series II SecurePay RightTime Election Form LAD-1198-B Transfer of Assets and Administrative Annuity Forms Contract Change Request LAD-1127 Transfer of Assets and Administrative Annuity Forms Dimensions IV - Payments, Allocations and Transfers LAD-1121 DIM IV Transfer of Assets and Administrative Annuity Forms Dimensions V - Payments, Allocations and Transfers LAD-1121 DIM V Transfer of Assets and Administrative Annuity Forms FIA Indexed Annuity Allocations LAD-1232 Transfer of Assets and Administrative Annuity Forms Internal Exchange Procedures LAD-1132 7/09 Transfer of Assets and Administrative Annuity Forms Investors Series - Allocation Adjustment Program LAD-1236-PVA-IS Transfer of Assets and Administrative Annuity Forms Investors Series - Payments, Allocations and Transfers LAD-1121-PVA-IS Transfer of Assets and Administrative Annuity Forms Lost Policy Statement LAD-1175 Transfer of Assets and Administrative Annuity Forms Payments, Allocations and Transfers for Aspirations Variable Annuity LAD-1121 Aspirations Transfer of Assets and Administrative Annuity Forms Pre-Determined Death Benefit Payout Election LAD-1153 Transfer of Assets and Administrative Annuity Forms Request for Transfer or Exchange of Assets **REQUIRED FOR TRANSFERS** LAD-1120 Transfer of Assets and Administrative Annuity Forms SecurePay Benefit Election for Aspirations Variable Annuity LAD-1233 Aspirations Transfer of Assets and Administrative Annuity Forms SecurePay RightTime Election Form for Aspirations Variable Annuity LAD-1198 Aspirations Transfer of Assets and Administrative Annuity Forms Stretch Annuity Information LAD-1166 Miscellaneous Miscellaneous Premium Financing Disc & Acknowledgement F-LAD-411 Miscellaneous Statement of Owner Intent (SOLI/IOLI) ICC14-PL702 Miscellaneous Trust Certification (SOLI/IOLI) ICC13-LAD410 Miscellaneous Non-Medical Declarations (Part 1A Medical) ICC12-402 Miscellaneous Continuation of Information ICC13-406A Miscellaneous Supplement to Life Insurance Application (SOLI/IOLI) ** REQUIRED FORM** ICC14-PL701 Miscellaneous Advertising Request Form MK-269 (5/00) Miscellaneous Description of Information Practices PL-DIP Miscellaneous Explanation of Coverage - for Broker/Dealer use only. Explanation of Coverage Miscellaneous HIV Consent Form U-461 Miscellaneous HIV Consent Form U-462 Miscellaneous Intent to Buy - fillable Intent to Buy Miscellaneous IVES Request for Transcript of Tax Return IRS Form 4506c Miscellaneous Life Insurance Illustration Certification & Acknowledgement PLX-588 Miscellaneous Military - Personal Commercial Solicitation Evaluation DD Form 2885 Miscellaneous Military DA Form 2056 Military DA Form 2056 Miscellaneous Military Sales Disclosure Form PLX-602 Miscellaneous Notice and Consent for Employer Owned Life Insurance EOLI Miscellaneous Order Form for Business Cards, Letterhead & Envelopes MK-283 (7/00) Miscellaneous Save Age Form ICC21-PN-100R Miscellaneous SEP IRA Forms for B Series VA, Investors Series VA, Dimensions IV VA, and Aspirations VA SEP IRA Agreement Miscellaneous UL Exchange F-1241 Miscellaneous W9 Tax Form W-9 Policy Service Forms Policy Service Forms Automatic Premium Loan SVC-101-PL Policy Service Forms Beneficiary Change SVC-102-PL Policy Service Forms Beneficiary Change of Last Will & Testament F-787 (9/99) Policy Service Forms Beneficiary Information Request LAD-1225 Policy Service Forms Beneficiary with Mode of Settlement SVC-103-PL Policy Service Forms Buyer's Guide for Annuities BG-13 Buyer's Guide for Annuities Policy Service Forms Change of Broker SVC-104-PL Policy Service Forms Co-Owner, Joint Owner, Ownership Common, Contingent SVC-106-PL Policy Service Forms Collateral Assignment Form SVC-130-PL Policy Service Forms Contingent Ownership SVC-105-PL Policy Service Forms Covered Insured Beneficiary SVC-107-PL Policy Service Forms Dividend and Coupon SVC-108-PL Policy Service Forms Duplicate Policy - Policy Not Lost SVC-109-PL Policy Service Forms Full Surrender Form SVC-110-PL Policy Service Forms Indexed Universal Life Fund Transfer/Allocation Change Form SVC-125-PL Policy Service Forms Loan Form SVC-111-PL Policy Service Forms Monthly Level Transfer (MLT) for Indexed Universal Life Insurance SVC-135-PL Policy Service Forms Name Change SVC-114-PL Policy Service Forms Non Forfeiture Options SVC-115-PL Policy Service Forms Notice Regarding Tax Treatment of Modified Endowment Contracts U-582 MEC Policy Service Forms Partial Assignment of Policy as Collateral Security SVC-128-PL Policy Service Forms Partial Surrender SVC-116-PL Policy Service Forms Policy Change Application No Evidence PLX-510 Policy Service Forms Policy Change with Evidence Packet ICC13-P526-DC packet Policy Service Forms Pre-Authorized Withdrawal SVC-117-PL Policy Service Forms Reinstatement Packet ICC13-P525 for DC Packet Policy Service Forms Release of Assignment SVC-131-PL Policy Service Forms Request to Exercise Option to Purchase Additional Life Insurance F-ILD-228 Policy Service Forms Service Request Form F-LAD-233 with PAW Policy Service Forms Statement of Health U-253-DC Policy Service Forms Surrender Paid Up Additions SVC-118-PL Policy Service Forms Tax Withholding on Periodic Annuity Payments LAD-1114 Policy Service Forms Telephone Withdrawal Authorization LAD-1155 Policy Service Forms Tobacco Use Questionnaire Packet (for Rate Reclassification) Tobacco Packet DC Policy Service Forms Transfer of Ownership SVC-119-PL Policy Service Forms VUL - Transfer Authorization LAD-1247 Policy Service Forms W-8BEN Tax Form W-8BEN Policy Service Forms W-8BEN Tax Form Instructions W-8BEN Instructions Policy Service Forms Waiver of Community Property SVC-120-PL Policy Service Forms Withdrawal Request Form LAD-1147 Examiner Forms (For Medical Examiner Use Only) Examiner Forms (For Medical Examiner Use Only) Part II Statements Made to Examiner PL-103_ICC13-406A Examiner Forms (For Medical Examiner Use Only) Authorization to Obtain and Disclose Information (HIPAA) ICC21-HIPAA3 medical examiner Examiner Forms (For Medical Examiner Use Only) Landmark Copy Drawing Test **FOR EXAMINER USE ONLY** F-LAD-402 Examiner Forms (For Medical Examiner Use Only) Supplemental Underwriting Application ** FOR MEDICAL EXAMINER USE ONLY ICC13-P226 Agent Specific Forms Agent Specific Forms Broker/Representative Report PLX-408 Agent Specific Forms APS Reimbursement Request Form PL-APS Agent Specific Forms Broker/Representative Report EDJ PLX-408 EDJ Agent Specific Forms VUL - Broker/Representative Report PLX-V408 Agent Specific Forms VUL - Broker/Representative Report EDJ PLX-V408 EDJ

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