Lincoln Benefit Life Company Annuity Application Form Page 2
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4H. TAX QUALIFICATION STATUS OF ANNUITY APPLIED FOR
I. BENEFICIARY*
Unless otherwise designated, the surviving beneficiaries in a class will share equally.
J. REPLACEMENT
none
K. REMARKS AND/OR SPECIAL INSTRUCTIONS
L. SIGNATURES
For Applicants in Arkansas, District of Columbia, Kentucky, Louisiana, Maine, New Mexico, Ohio, Pennsylvania, and Tennessee:
For Applicants in Colorado:
For Applicants in New Jersey:
For Applicants in Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a
number to be issued to me), (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been
notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c)
the IRS has notified me that I am no longer subject to backup withholding, and (3) I am a U.S. person (including U.S. resident alien). The Internal
Revenue Service does not require your consent to any provisions of this document other than the certification required to avoid backup withholding.
AGENT: To the best of your knowledge will this contract replace or change any existing life insurance or annuity in this or any other company?
Print Agent’s Name
Agent Number - %
Signature of Agent
Agent’s Phone Number
Print Additional Agent’s Name
Agent Number - %
Signature of Additional Agent
Agent’s Phone Number
AA-2001-1
Page 2
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