Upon segment maturity, allocate Segment Proceeds to the following accounts. Select the FROM account and TO account on the chart provided. In the absence of any Segment Proceeds allocation instructions, your policy’s Segment Proceeds will automatically be reallocated 100% to new segments of the same Indexed Account. If additional space is needed for these instructions, please submit a separate page along with this form.

This option is not available for policies that have Policy Value in any Indexed Account. If any Policy Value is allocated to an Indexed Account, this option is discontinued and charges will be deducted pro-rata. If all Policy Value is later removed from the Indexed Accounts, you must request a new allocation of monthly charges.

I understand and agree that:

By checking one of the boxes below, I am authorizing The Company to accept telephone and Internet transfers and allocation changes. Telephone and Internet transfers and allocation changes will also be subject to the terms and conditions of the policy, and the administrative requirements of The Company.

The Company will honor telephone and Internet instructions from anyone who provides correct identifying information. The Company, its agents or representatives of employees who act on its behalf will not be subject to any claim, liability, loss, expense or cost if acted on in good faith upon telephone or Internet instructions it reasonably believes to be genuine in reliance on this signed authorization.

The Company, at its option alone and without prior or subsequent notice to the Owner(s), or any other person or representative of the Owner(s), may record all or part of any telephone conversation containing telephone transfer and/or allocation change instructions.

All terms of this Authorization are binding upon the agents, heirs and assignees of the Owner(s).

This Telephone and Internet Transfer/Allocation Change Authorization will be effective until such time as (a) written revocation is received by The Company’s Service Office, or (b) The Company discontinues this privilege, whichever occurs first.

I authorize The Company to accept telephone and Internet instructions from me or any co-owner.

I authorize The Company to accept telephone and Internet instructions from me, any co-owner or our Registered Representative.

The Asset Allocation Balancer Service will only move amounts among the Investment Accounts selected; it will not move amounts to or from the Fixed Account or any Indexed Account. This service will automatically move amounts among your specified Investment Accounts as frequently as you indicate below in number 9 to maintain your chosen percentages in each account. To elect this service, check box A or B and provide details as required.

Rebalance based on the percentages selected in the Investment Allocation of Net Premiums section of this form without regards to any amounts allocated to the Fixed Account or any Indexed Account.

Rebalance based on the listed percentages below:

Frequency of Rebalancing

I understand that under the applied for policy:

the amount of the insurance benefits, the duration of the insurance coverage, or both, may be variable or fixed;

the amount of the insurance benefits, the duration of the insurance coverage, and the policy/account value, may increase or decrease, even to the extent of being reduced to zero, depending on the experience of the chosen investment options and are not guaranteed as to dollar amount. Illustrations of benefits, including death benefits, policy/account and cash surrender values are available on request; and

if the net cash surrender value is insufficient to pay the charges when due and there is not a no-lapse guarantee in effect, your policy can terminate or lapse due to insufficient premiums or poor investment option performance.