Stock Order Form Instructions
Item 1, 2 and 3 -Fill in the number of shares that you wish to purchase in item 1, and the total payment amount due in item 2. The amount due is determined by multiplying the number of shares ordered by the subscription price of $10.00 per share. The minimum number of shares you may order is 25 shares. The maximum number of shares you may order is printed in section 3 on the reverse side of this form. See the Prospectus section titled “The Conversion and Offering – Limitations on Purchases of Common Stock” for more information on purchase limitations. Payment for shares may be made by check, bank draft or money order payable to “Computershare Trust Company, N.A., as escrow agent for Vericity, Inc.” DO NOT MAIL CASH. Payments received during the offering will be placed in an escrow account at Computershare Trust Company, N.A., who will serve as the escrow agent until completion of the offering.
Item 4 - Check the appropriate box(s) if you are a Director or Officer of Members Mutual Holding Company, and/or an Employee of Fidelity Life Association or Efinancial, LLC.
Item 5 - Check the box, if applicable, and provide the requested information. Attach a separate page, if necessary. In the Prospectus dated , 2019, please see the section entitled “The Conversion and Offering—Limits on Purchases of Common Stock” for more information regarding the definition of “associate” and “acting in concert.”
Item 6 - The stock transfer industry has developed a uniform system of shareholder registrations that we will use in the issuance of Vericity, Inc. common stock. Please complete this section as fully and accurately as possible, and be certain to supply your social security or Tax I.D. number(s) and your daytime and evening phone numbers. We will need to call you if we cannot execute your order as given. If you have any questions regarding the registration of your stock, please consult your legal advisor or contact the Stock Information Center at ( ) - . Subscription rights are not transferable. If you are an eligible member of Members Mutual, to protect your priority over other purchasers as described in the prospectus you must take ownership in at least one of the eligible policyholder’s names.
Item 7 - Sign and date the form where indicated. Before you sign please read carefully and review the information which you have provided and read the acknowledgement. All persons named in section 6 on the reverse side must sign the order form. Please review the Prospectus dated , 2019 including the section titled “Risk Factors”, before making an investment decision.
Stock Ownership Guide
Individual - The stock is to be registered in one person’s name only. You may not list beneficiaries for this ownership.
Joint Tenants – Joint tenants with rights of survivorship identifies two or more owners. When stock is held by joint tenants with rights of survivorship, ownership automatically passes to the surviving joint tenant(s) upon the death of any joint tenant. All owners must agree to the transfer or sale of shares held by joint tenants.
Corporation/Partnership – If the eligible Fidelity Life Association policyholder is a business concern the business may exercise its subscription right to purchase stock. The stock must be registered in the name of the business and may not be registered in the name of business owners, partners, officers of the business, etc. Please provide the full legal name, address and Tax I.D# of the business. Please contact the Stock Information Center to verify subscription rights and purchase limitations.
Individual Retirement Account- Individual Retirement Account (“IRA”) holders may be able to make stock purchases from their existing IRA if it is a self-directed IRA. Please contact your financial advisor or self-directed IRA provider as quickly as possible to explore this option, as it may take a number of weeks to place a subscription using IRA funds. Suggested registration for IRA’s (confirm with your IRA provider):
On Name Line 1 - list the name of your IRA custodian, followed by “CUST”
On Name Line 2 - FBO (for benefit of) YOUR NAME [IRA, ROTH IRA, etc.]
Address will be that of the broker / trust department to where the statement of ownership will be sent.
The Reporting Tax ID# should be that of your custodian. Provide your Social Security Number on line 2 of the registration area.
Please listyour phone numbers,not the phone numbers of your broker / trust department.
Trust/Fiduciary - Generally, fiduciary relationships (such as Trusts, Estates, Guardianships, etc.) are established under a form of trust agreement or pursuant to a court order. Without a legal document establishing a fiduciary relationship, your stock may not be registered in a fiduciary capacity.
For additional information, refer to the prospectus dated [ ] or call our Stock Information Center, toll free, at ( ) - , Monday through Friday, between 10:00 a.m. and 4:00 p.m., Central Time. The stock information center will be closed on weekends and holidays.