Variable Annuity Withdrawal Request Form - PRIME

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Variable Annuity Withdrawal Request FormContract Number Owner(s) NameName of Payee(s) If Other Than Owner(s)Address To Which Check Should Be Sent If Other Than Owner(s)City State Zip CodeIn accordance with the terms of this Contract, the following action is authorized: Total Withdrawal The Contract must be submitted or the Lost Contract Statement, on the reverse side, completed. Partial Withdrawal As requested below: Select Only One: $______________ _______% of Contract Value Maximum Free Withdrawal Indicate Source of Payment (Use Whole Percentages Only)If no source is indicated, the amount withdrawn will be deducted from each portfolio in the proportion that it bears to the total Contract Percentage

Variable Annuity Withdrawal Request Form Contract Number Owner(s) Name Name of Payee(s) If Other Than Owner(s) Address To Which Check Should Be Sent If Other Than Owner(s)

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