AA 3393 Page 1 of 5
Principal
Financial
Group
Logo
Benefit Variable
Mailing Address: Principal Life Universal Life Insurance
Des Moines, IA 50392-0001 Insurance Company Supplemental Application
- --------------------------------------------------------------------------------
1. Print full name of Proposed Insured Policy Number
----------------------------------------------------------------------------
Print full name of Owner
----------------------------------------------------------------------------
- --------------------------------------------------------------------------------
2. Complete the sections for: Required Sections Optional Sections
----------------- -----------------
A. New Business............................................................... 1, 4, 5, & 9 3, 6 & 7
B. Adjustments to Existing Business........................................... 1 & 9 3, 4, 5, 6 & 7
C. Term Conversions........................................................... 1, 4, 5, & 9 3, 6 & 7
D. Adding/Changing Dollar Cost Averaging or Automatic Portfolio Rebalancing...
1, 7, & 9 (N/A)
- --------------------------------------------------------------------------------
Note: Section 10 must be completed when sold by a Registered Representative of a
Broker/Dealer other than Princor Financial Services Corporation. A selling
agreement between the Broker/Dealer and Princor Financial Services Corporation
must be in place.
- --------------------------------------------------------------------------------
3. Telephone and Internet Authorization:
I (We) want telephone transaction services as described in the prospectus
for myself (ourselves) and the sales representative. Telephone instructions
received from the sales representative will be binding on all policy
owners................................................... __Yes __No
I (We) want Internet transaction services as described in the prospectus
for myself (ourselves) and the sales representative. Internet instructions
received from the sales representative will be binding on all policy
owners.................................................... __Yes __ No
If these boxes are not checked, telephone and Internet services are not
available. Telephone or Internet instructions received from any joint
policy owner will be binding on all owners.
- --------------------------------------------------------------------------------
4. Electronic Prospectus Authorization:
I (We) want electronic delivery of the prospectuses and prospectus
supplements in lieu of paper versions. I (We) understand that this
consent is effective until I (We) revoke it............. __Yes __ No
- -------------------------------------------------------------------------------
5. Allocation Percentages for:
Premium Payments Premiums include the initial payment and all planned
periodic premiums. The net premium is the premium paid less the premium
expense charge. During the examination period the Company will allocate net
premiums to the money market division if state law requires us to refund
the initial premiums. The Company will re-allocate initial net premiums to
the requested division(s) at the end of the examination period. If state
law does not require refund of premiums paid, the initial net premiums can
be immediately allocated to any available division as directed in the
application, unless you direct otherwise. If the purchase of this policy
falls within the definition of a replacement under state law, the Company
reserves the right to retain the initial net premiums in the money market
division beyond the examination period to correspond to the free look
period of a particular state's replacement requirements. Unless you change
them, your initial percentages apply to future allocations of premiums.
The sum of the percentages for all Divisions must equal 100%.
AIM V.I. Aggressive Growth ----- % MFS(R)VIT Emerging Growth ------%
AIM V.I. International Growth ----- % MFS(R)VIT MidCap Growth ------%
AIM V.I. Premier Equity ----- % MFS(R)VIT New Discovery ------%
American Century VP Income & Growth ----- % MFS(R)VIT Value ------%
American Century VP International ----- % Neuberger Berman AMT Guardian ------%
American Century VP Ultra ----- % Principal Bond ------%
American Century VP Value ----- % Principal Capital Value ------%
Berger IPT MidCap Value ----- % Principal Equity Growth (Morgan Stanley) ------%
Dreyfus DIP Appreciation ----- % Principal Government Securities ------%
Dreyfus DIP Core Value ----- % Principal Growth ------%
Dreyfus DIP Founders Discovery Portfolio ----- % Principal International ------%
Dreyfus DIP Founders Growth Portfolio ----- % Principal International SmallCap ------%
Dreyfus DIP Quality Bond ----- % Principal Largecap Blend (Federated) ------%
Dreyfus DIP SmallCap ----- % Principal LargeCap Growth (Janus) ------%
Dreyfus Socially Responsible Growth ----- % Principal LargeCap Value (Bernstein) ------%
Fidelity VIP II Asset Manager ----- % Principal MidCap ------%
Fidelity VIP II Contrafund ----- % Principal MidCap Growth (Dreyfus) ------%
Fidelity VIP Equity-Income ----- % Principal MidCap Growth Equity (Turner) ------%
Fidelity VIP Growth ----- % Principal MidCap Value (Neuberger Berman) ------%
Fidelity VIP High Income ----- % Principal Money Market ------%
Fidelity VIP MidCap ----- % Principal Real Estate (Principal Mgt. Corp.) ------%
Franklin Income Securities ----- % Principal SmallCap (Invista) ------%
Franklin Mutual Discovery ----- % Principal SmallCap Growth (Berger) ------%
Franklin Mutual Shares ----- % Principal SmallCap Value (J.P. Morgan) ------%
Franklin Rising Dividends ----- % Putnam VT Growth & Income ------%
Franklin Value Securities ----- % Putnam VT International Growth ------%
INVESCO VIF-Dynamics ----- % Putnam VT Voyager ------%
INVESCO VIF-Equity Income ----- % Vanguard VIF Balanced ------%
INVESCO VIF-Health Sciences ----- % Vanguard VIF Equity Index ------%
INVESCO VIF-Small Company Growth ----- % Vanguard VIF MidCap Index ------%
INVESCO VIF-Technology ----- % Wells Fargo VT Asset Allocation ------%
Janus Aspen Aggressive Growth ----- % Wells Fargo VT Equity Income ------%
Janus Aspen Balanced ----- % Wells Fargo VT Large Company Growth ------%
Janus Aspen Core Equity ----- % ----------------------------------------- ------%
Janus Aspen Flexible Income ----- % ----------------------------------------- ------%
Janus Aspen International Growth ----- % ----------------------------------------- ------%
Janus Aspen Strategic Value ----- % ----------------------------------------- ------%
Janus Aspen Worldwide Growth ----- % ----------------------------------------- ------%
JP Morgan Bond ----- % ----------------------------------------- ------%
JP Morgan SmallCap ----- % ----------------------------------------- ------%
(continued on next column) Total 100 %
- --------------------------------------------------------------------------------
6. Monthly Policy Charges:
Note: IF THIS SECTION IS NOT COMPLETED, THE MONTHLY POLICY CHARGES WILL BE
ALLOCATED IN THE SAME MANNER AS PREMIUMS. The deduction for the monthly
policy charge includes the cost of insurance and the cost of additional
benefits provided by any rider in force for the policy month, and the
current asset based charge.
The Company will withdraw the monthly policy charge from the policy value.
The sum of the percentages for all the divisions must equal 100%.
Check One: Allocated in the same manner as premium ------
Prorated based on the balance of the owner's investment accounts ------
As Below ------
Division/Account Percent Division/Account Percent
---------------- ------- ---------------- -------
-------------------------------------- ----------% ---------------------------------------- ---------%
-------------------------------------- ----------% ---------------------------------------- ---------%
-------------------------------------- ----------% ---------------------------------------- ---------%
-------------------------------------- ----------% ---------------------------------------- ---------%
- --------------------------------------------------------------------------------
7. Scheduled Transfer Options: (You may choose Dollar Cost Averaging or
Automatic Portfolio Rebalancing.)
___ Dollar Cost Averaging - Allows for transfer of money between Separate
Account Divisions on a scheduled basis.
Frequency: ___ Monthly ___ Quarterly ___ Semiannually ___ Annually
Initial Transfer Date / /
----- ------ -------
M D YR
(not available on 29, 30, or 31st of month)
- ----------------------------------------------------------------------------
Transfer Out (-) Transfer In (+)
Division/Account Amount Percent Division/Account Amount Percent
1. $ % 1. $ %
-------------------- ------------ ---------- -------------------- -------------- ---------
2. $ % 2. $ %
-------------------- ------------ ---------- -------------------- -------------- ---------
3. $ % 3. $ %
-------------------- ------------ ---------- -------------------- -------------- ---------
4. $ % 4. $ %
-------------------- ------------ ---------- -------------------- -------------- ---------
5. $ % 5. $ %
-------------------- ------------ ---------- -------------------- -------------- ---------
6. $ % 6. $ %
-------------------- ------------ ---------- -------------------- -------------- ---------
Note: Dollar Cost Averaging will begin on the first Monthly Date
following receipt of this form, unless another date is requested
above.
__ Automatic Portfolio Rebalancing - This feature allows for maintaining
the investment allocation that was originally established. It allows
for rebalancing monthly, quarterly, semiannually or annually.
Also, you may elect to rebalance upon request if you contact the Home
Office. Frequency: Select one from each Category A and B:
A. __ Monthly __ Quarterly __ Semiannually __ Annually __ Fiscal Quarter
B. __ Based on Policy Date __ Specified future date / /
--- -- ---
M D YR
(not available on 29, 30, or 31st of month)
Investment Division Options:
Rebalance my policy in the following way:
Division/Account Percent Division/Account Percent
__________________________ _______% __________________________ _______%
__________________________ _______% __________________________ _______%
__________________________ _______% __________________________ _______%
__________________________ _______% __________________________ _______%
- --------------------------------------------------------------------------------
8. Fraud Notices:
Arkansas: Any person who knowingly and with intent to defraud any insurance
company or other person submits a statement of claim or any application
form containing any materially false information or conceals for the
purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act which is a crime. Such actions may be
considered felonies and subject to criminal and civil penalties, including
imprisonment and fines. In New York, civil penalties cannot exceed five
thousand dollars and the stated value of the claim for each such violation.
Colorado: It is unlawful to knowingly provide false, incomplete, or
misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. Penalties may include
imprisonment, fines, denial of insurance, and civil damages. Any insurance
company or agent of an insurance company who knowingly provides false,
incomplete, or misleading facts or information to a policyholder or
claimant for the purpose of defrauding or attempting to defraud with regard
to a settlement or award payable from insurance proceeds shall be reported
to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
District of Columbia/Tennessee: WARNING: IT IS A CRIME TO PROVIDE FALSE,
MISLEADING, OR INCOMPLETE INFORMATION TO AN INSURANCE COMPANY FOR THE
PURPOSE OF DEFRAUDING THE COMPANY OR ANY OTHER PERSON. PENALTIES INCLUDE
IMPRISONMENT AND/OR FINES AND DENIAL OF INSURANCE BENEFITS.
Kentucky/Maine: Any person, who knowingly and with intent to defraud any
insurance company or other person, files an application for insurance
containing any materially false information or conceals for the purpose of
misleading information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime.
Louisiana: Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or knowingly presents false information in
an application for insurance is guilty of a crime and may be subject to
fines and confinement in prison.
New Jersey: Any person who includes any false or misleading information on
an application for an insurance policy is subject to criminal and civil
penalties.
New Mexico: Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or knowingly presents false information in
an application for insurance is guilty of a crime and may be subject to
civil fines and criminal penalties.
Ohio: Any person who, with intent to defraud or knowing that he is
facilitating a fraud against an insurer, submits an application or files a
claim containing a false or deceptive statement is guilty of insurance
fraud.
Pennsylvania: Any person who knowingly and with intent to defraud any
insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals
for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime and subjects
such person to criminal and civil penalties.
- --------------------------------------------------------------------------------
9. Signature
I have read this application and have had the opportunity to read the
prospectuses. I authorize the instructions in this application. I have
been given the opportunity to ask questions regarding this policy, and
they have been answered to my satisfaction. I understand the investment
objectives of the Investment Account Divisions and/or Fixed Account for
which I am applying and believe they fit with my investment objective(s).
All of the statements in this application are true and complete to the
best of my knowledge and are the basis of any life insurance issued.
---------------------------------------------------------------
Print Name of Owner
--------------------------------------------------------------- ----------------------------------------------------------
Authorized Signature Indicate Title of Authorized Person
To be completed by the Registered Representative:
Signed at Signature
---------------------------------------------------- -------------------------------------------------
City State Date
- --------------------------------------------------------------------------------
10. To Be Completed by Selling Firm
- --------------------------------------------------------------------------------
Dealer's Name Telephone
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
Reviewed by Date
Registered Principal:
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
MM 1791-3 Page 1 of 2
Princor
Financial
Services
Corporation
Logo
Variable Products
Principal Financial Group Princor Financial Broker/Dealer
Des Moines, IA 50392-0200 Services Corporation Account Form
Owner Information
- --------------------------------------------------------------------------------
Primary Owner Name (First, MI, Last) Date of Birth Soc. Sec. No. or Fed. Tax
(MM/DD/YYYY) I.D. No.
- -------------------------------------------------------------------------------
Joint Owner Name (First, MI, Last) Date of Birth Soc. Sec. No. or Fed. Tax
(MM/DD/YYYY) I.D. No.
- --------------------------------------------------------------------------------
Street Address E-Mail Address
- --------------------------------------------------------------------------------
City State Zip Home Phone
( )
- --------------------------------------------------------------------------------
State of Primary Residence Is Registered Representative registered in
client's resident state?
__ Yes __ No
- --------------------------------------------------------------------------------
Your Citizenship is: Country
__U.S. __ Resident Alien (1078) __ Non-Resident Alien (W-8)- Indicate
- --------------------------------------------------------------------------------
Retired Name of Employer Nature of Business
(If Retired, List Prior
Occupation and Employer)
__ Yes __ No
- -------------------------------------------------------------------------------
Employer's Street Address Occupation Years with Present
Employer or in Retirement
- --------------------------------------------------------------------------------
City State Zip Business Phone
( )
- --------------------------------------------------------------------------------
Owner(s) Suitability Information (used to help confirm that transactions are
consistent with your goals)
- --------------------------------------------------------------------------------
Primary Investment Objective* Secondary Investment Risk Exposure*
Objective*
(check only one)
__Variable Life - Death Benefit __Variable Annuity - Long __Income __Long-term growth __Low __Moderate __High
Term/Retirement
- -------------------------------------------------------------------------------
Marital Years of Number of Fed. Tax Estimated Annual Liquid Net Worth* Other Investments and
Status Investment Dependents Bracket* Income (Do Not Include Primary Savings*
Experience* Residence)
% $ $ $
- -------------------------------------------------------------------------------------------------------------------------------
*Corporate/Trust Applicants must complete for suitability review.
Source of Funds To Be Invested
- -------------------------------------------------------------------------------
__Current Income __Personal Savings __CD/Money Market Fund __Mutual Fund Liquidation*
__Qualified Plan __Insurance Proceeds __IRA Rollover* __Transfer from an Annuity Contract*
Distribution (Surrender/Loan)* __Other
*Please complete the Variable Contract Switch Disclosure below.
Variable Contract Switch Disclosure
- --------------------------------------------------------------------------------
I understand that it is Princor's policy not to recommend one financial product
be replaced with another unless a person's investment or personal objectives can
be served better by such switching/replacing. I understand that I may incur a
front-end sales charge, contingent deferred sales charge, or surrender charges.
I understand I may incur income taxes due to this transaction. If my original
investment was in a family of funds or a variable contract, I realize that I
might be able to exchange to a fund or separate account within the family or
contract without incurring a sales charge.
I made my original purchase approximately _____ year(s) ago.
__I am making this exchange because: __Lower Cost Structure __Need for Death Benefit __Need for Tax-Deferral
__Other_________________________________________________________________
_______(Please initial)
Complete this section only for Non-Principal Variable Annuity Applications
- --------------------------------------------------------------------------------
As a result of your purchase of this product, will you be receiving a purchase
payment credit or bonus to your variable annuity account? ___Yes ___No
If answered yes: I have received information on my purchase options with cost
comparisons of each and I understand that, by selecting this option, my account
might be subject to additional charges. _____________ (Please initial)
Financial Institution Disclosure (applicable when Representatives working with
clients in a bank affiliation)
- --------------------------------------------------------------------------------
I understand that the investment product that I have purchased is offered
through a Registered Broker Dealer. My Registered Representative has disclosed
to me, orally and in writing, that the securities products purchased or sold
are:
o Not insured by the Federal Deposit Insurance Corporation [FDIC];
o Not deposits or other obligations of the financial institution and are not
guaranteed by the financial institution;
o Not required to be purchased as a condition of receiving credit approval
from the financial institution; and
o Subject to investment risks, including possible loss of principal invested.
Signature
- --------------------------------------------------------------------------------
Sign below exactly as your name appears on this form. For joint registration,
all owners must sign.
I acknowledge that I have received and have had the opportunity to review an
appropriate and current prospectus. I understand that my registered
representative may change broker dealer affiliations at some time in the future.
I acknowledge and agree that Princor Financial Services Corporation may transfer
my account(s) to such a new broker dealer upon request by the registered
representative without prior notification to me.
Please note that the Customer Agreement contains a pre-dispute arbitration
agreement which is set forth in paragraphs 8 and 9 of the enclosed Customer
agreement. I acknowledge receiving a copy of this agreement.
- ----------------------------------------------------------------------------------------------------------------------------------
Owner's Signature Date (MM/DD/YYYY)
- ----------------------------------------------------------------------------------------------------------------------------------
- ----------------------------------------------------------------------------------------------------------------------------------
Joint Owner's Signature Date (MM/DD/YYYY)
- ----------------------------------------------------------------------------------------------------------------------------------
- ----------------------------------------------------------------------------------------------------------------------------------
Registered Representative Printed Name Registered Representative's Signature RR Detail Code & Percent
- ----------------------------------------------------------------------------------------------------------------------------------
- ----------------------------------------------------------------------------------------------------------------------------------
Registered Representative Printed Name Registered Representative's Signature RR Detail Code & Percent
- ----------------------------------------------------------------------------------------------------------------------------------
- ----------------------------------------------------------------------------------------------------------------------------------
Registered Principal's Approval and Acceptance Date of Approval
(MM/DD/YYYY)
- ----------------------------------------------------------------------------------------------------------------------------------
MM 1791-2 Page 2 of 2
Customer Agreement - This Customer Agreement is between the Account Owner(s)
(referred to as I) and Princor Financial Services Corporation (referred to as
You).
- -------------------------------------------------------------------------------
1. Successors
This agreement and its provisions shall be continuous, and shall be for the
benefit of your present organization, and any successor organization or
assigns, and shall be binding upon me and/or the estate, executors,
administrators and assigns.
2. Age
If an individual, I represent that I am of legal age.
3. Orders and Statements
Reports of the execution of orders and statements of the contract shall be
conclusive if not objected to in writing. The former within two days and
the latter within ten days, after forwarding to me by mail or otherwise.
4. Force Majeure
You shall not be liable for loss or delay caused directly or indirectly by
war, natural disasters, government restrictions, exchange or market rulings
or other conditions beyond your control.
5. Joint Owners
This contract is owned jointly, unless you are notified otherwise and the
required documentation is provided, the contract(s) shall be held jointly
with right of survivorship (payable to either, or the survivor). Each joint
owner irrevocably appoints the other as attorney-in-fact to take all action
on their behalf and to represent them in all respects in connection with
this Agreement. You shall be fully protected in acting but shall not be
required to act upon the instructions of either joint owner. Each shall be
liable, jointly and individually, for any amounts due to you pursuant to
this Agreement, whether incurred by either or both.
6. Address
Communications may be sent to me at the address which is on file at your
office, or at such other address as may hereafter be given to you in
writing. All communications so sent, whether by mail, telegraph, messenger
or otherwise, shall be deemed given to me personally, whether actually
received or not.
7. Recording Conversations
I understand and agree that for our mutual protection you may
electronically record any of our telephone conversations.
8. ARBITRATION DISCLOSURES
* ARBITRATION IS FINAL AND BINDING ON THE PARTIES.
* THE PARTIES ARE WAIVING THEIR RIGHT TO SEEK REMEDIES IN COURT,
INCLUDING THE RIGHT TO A JURY TRIAL.
* PRE-ARBITRATION DISCOVERY IS GENERALLY MORE LIMITED THAN AND DIFFERENT
FROM COURT PROCEEDINGS.
* THE ARBITRATORS' AWARD IS NOT REQUIRED TO INCLUDE FACTUAL FINDINGS OR
LEGAL REASONING AND ANY PARTY'S RIGHT OR APPEAL OR TO SEEK
MODIFICATION OF RULINGS BY THE ARBITRATORS IS STRICTLY LIMITED.
* THE PANEL OF ARBITRATORS WILL TYPICALLY INCLUDE A MINORITY OF
ARBITRATORS WHO WERE OR ARE AFFILIATED WITH THE SECURITIES INDUSTRY.
9. AGREEMENT TO ARBITRATE CONTROVERSIES
IT IS AGREED THAT ANY CONTROVERSY BETWEEN US ARISING OUT OF YOUR BUSINESS
OR THIS AGREEMENT, SHALL BE SUBMITTED TO ARBITRATION CONDUCTED BEFORE THE
NATIONAL ASSOCIATION OF SECURITIES DEALERS INC. AND IN ACCORDANCE WITH ITS
RULES. ARBITRATION MUST BE COMMENCED BY SERVICE UPON THE OTHER PARTY OF A
WRITTEN DEMAND FOR ARBITRATION OR A WRITTEN NOTICE OF INTENTION TO
ARBITRATE.
NO PERSON SHALL BRING A PUTATIVE OR CERTIFIED CLASS ACTION TO ARBITRATION,
NOR SEEK TO ENFORCE ANY PRE-DISPUTE ARBITRATION AGREEMENT AGAINST ANY
PERSON WHO HAS INITIATED IN COURT A PUTATIVE CLASS ACTION OR WHO IS A
MEMBER OF A PUTATIVE CLASS ACTION WHO HAS NOT OPTED OUT OF THE CLASS WITH
RESPECT TO ANY CLAIM ENCOMPASSED BY THE PUTATIVE CLASS ACTION UNTIL; (I)
THE CLASS CERTIFICATION IS DENIED; (II) THE CLASS ACTION IS DECERTIFIED; OR
(III) THE CUSTOMER IS EXCLUDED FROM THE CLASS BY THE COURT. SUCH
FORBEARANCE TO ENFORCE AN AGREEMENT TO ARBITRATE SHALL NOT CONSTITUTE A
WAIVER OF ANY RIGHTS UNDER THIS AGREEMENT EXCEPT TO THE EXTENT STATED
HEREIN.
Securities are offered through Princor Financial Services Corporation, a company
of the Principal Financial Group(R), 711 High Street, Des Moines, Iowa 50392.
Princor Financial Services Corporation member SIPC. 800-247-4123