32-77940-02 Investment Advisor Authorization.qxd

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32-77940-02 Investment Advisor Authorization.qxd Powered By Docstoc
					                             Client VA / VUL Policy Feature Acknowledgement

Please confirm your acknowledgement and understanding of the below information regarding the management of
your Variable Annuity (VA) or Variable Universal Life (VUL) policy.

The Risk Acknowledgement section (Part 1, Section 6) of the Hanlon Investment Management Agreement states: VA
and VUL contracts may contain riders that provide for certain features, benefits, and guarantees. The ongoing
deduction of our management fees from your Account, trading activity, and/or use of certain subaccounts /investment
options may cause your contract to experience a reduction in these features, benefits and guarantees, such as a
reduction to death benefits, income guarantees, appreciation guarantees, tax on distributions status, etc. to the extent
that they exist. You acknowledge a complete and full understanding of the specific features, benefits and
guarantees in your contract and the corresponding possible negative effect that our ongoing management
may have and you accept this condition. Please carefully review the below items:

  o   Policy features (riders, living benefits, guarantee of withdrawal or income, death benefit guarantees, policy
      value step ups etc.) may be detrimentally impacted or terminated by the withdrawal of management fees and /
      or trading activity.
  o   The withdrawal of management fees may result in a taxable event (tax due on distribution amount, early
      withdrawal penalty, etc.) and may be subject to issuer surrender charges.
  o   Some policy features/programs may prevent Hanlon Investment Management (HIM) from implementing
      portfolio management strategies and could result in HIM rejecting the policy before or after the inception of
      management services.
  o   Trade limitations: certain issuers may implement restrictive trading policies (limitation on the number of trades
      allowed, reduction in available investment options, etc.) that may result in HIM rejecting the policy before or
      after the inception of management services.
  o   Special programs that periodically rebalance policies such as Systematic Rebalancing, Automatic Asset
      Allocation, etc. must be cancelled prior to the inception of portfolio management. HIM will not be liable for any
      negative impact resulting from special programs not being terminated prior to management inception or for
      programs implemented after management inception.
  o   Special programs that direct the investment of additional dollars / payments / premiums (Future Allocation,
      Dollar Cost Averaging, etc.) will be updated with each trade order that HIM submits for processing. HIM will
      not be liable for any negative impact due to the issuer neglecting to adequately advise as to the existence of
      these programs prior to management inception or for programs implemented after management inception.
  o   “Fixed” or “Guaranteed Rate” investment options: HIM procedure is to liquidate these assets as quickly as
      allowed by the issuer without regard to Market Value Adjustment (MVA) or the ability to utilize the option in the

PLEASE NOTE: The above should NOT be considered a comprehensive list of conditions that could have negative
policy impact. The existence of the above could result in HIM rejecting a policy before or after the inception of
management services. Furthermore, HIM will not be liable for any adverse conditions resulting from implementation
or changes to policy features after management inception. If you would like management fees deducted from an
account other than your VA / VUL, please use the HIM ACH Form.

Please be advised that NONE of the referenced policy features are provided, underwritten, or represent any part of
the investment management services delivered by Hanlon Investment Management, Inc.

Policy Issuer: _____________________________________              Policy Number: __________________________

Owner’s Name (Printed): __________________________________________________________

Owner’s Signature: ____________________________________________________________ Date: ___________

Joint Owner’s Name (Printed): ____________________________________________________

Joint Owner’s Signature: ________________________________________________________ Date: ___________

Advisor’s Signature: _____________________________________________________________Date:___________
                                                                                           Investment Advisor Authorization

Questions? Call our National Service Center at 1-800-888-2461.


 Use this form to establish authority for your investment advisor. Complete the entire form. Please type or print.

 1. Provide General Account Information

 Contract/Account Number_______________________________ Plan Number or Name ______________________________________
                                                                                       (Applicable to Employer Retirement Plans only)

 Name of Owner/Participant        ____________________________________________________________________________________________
                                  First                               MI                     Last

 Mailing Address    ______________________________________________________________________________________________________
                    Street Address                                   City                    State            ZIP Code

 Social Security Number/Tax I.D. Number ___________________________________

 Daytime Phone Number ___________________________________ Home Phone Number                __________________________________

 2. Identify Investment Advisor

 Name of Investment Advisor __________________________________________________________________________________________
                                   First                                MI                     Last
 Type of Advisor (check one):          Firm      Individual

 Mailing Address    ______________________________________________________________________________________________________
                    Street Address                                   City                    State            ZIP Code

 Daytime Phone Number         _______________________________________    Fax Number ________________________________________

 3. Confirm Advisor Fees

 Please indicate your investment advisor’s policy:
      No advisory fees will be deducted from my account.
      Advisory fees (if applicable) will be deducted from my account.
    Note: Complete section 5 if advisory fees will be deducted.

 4. Establish Advisor Authorization

 Please read the advisor authorization.
 Transfer Authorization.
 I authorize Security Benefit Life Insurance Company, Security Financial Resources, Inc., Security Distributors, Inc. and
 their affiliates (“Security Benefit”) to release account information to the Advisor and to comply with written, telephone,
 internet or faxed instructions from the Advisor listed for the Account.
 Fee Payment Authorization.
 If authorized, fees will be deducted from the Investment Options in the same proportion as the Value is allocated among
 these Investment Options as of the date each fee is deducted. I acknowledge and understand that:
     (a) Security Benefit is not responsible or liable to determine that the instructions received from the Advisor are in
         compliance with the advisory services agreement.
     (b) Security Benefit has no duty to inquire into the amount withdrawn.
     (c) Partial withdrawals to deduct fees may incur withdrawal charges. If charges are required, Security Benefit will
         liquidate a larger percentage or dollar amount than the amount requested.

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4. Establish Advisor Authorization (continued)

I hereby authorize Security Benefit to:
   (a) Comply with written requests from the Advisor to liquidate a given dollar amount to pay Advisor fees (“fees”) under
       an advisory services agreement executed by the Owner(s).
   (b) Liquidate the additional percentage or dollar amounts required as a withdrawal charge.

5. Withdrawals/Tax Status

Please complete this section ONLY if your advisor deducts fees, as determined in section 3.
Check one of the following:
   401 funding vehicles, 403(b)(7) custodial accounts, 457, SEP/IRA accounts or IRA custodial accounts:
   I declare that the Account is solely responsible for the advisory fees set forth in the agreement which I have executed
   with the Advisor.
   IRA Annuity, SEP/IRA Annuity or 403(b) Annuity:
   I declare that I have entered into an agreement with the Advisor that states that the Contract is solely responsible for
   the advisory fees. Fee liquidations for these account types will not be reported to the IRS. However, Security Benefit
   reserves the right to change this tax reporting position at any time. If this position is changed, the Owner(s) and
   Advisor will receive written notice. In addition, any changes will not alter the future payments authorized under
   this form.
   Non-qualified Annuity:
   I understand that liquidation of accumulation units under the Contract to pay fees for non-qualified annuity contracts is
   considered to be constructive income to the extent of the Contract gain and therefore any such gain is subject to
   income tax and may be subject to penalty tax prior to attaining age 591/2.

6. Access to Account/Waiver of Confirmation

Your Advisor may provide financial reports for you. Please confirm with your representative that your Advisor provides
these services. Please complete this section if this option is provided by your Advisor.
   I understand that Rule 10b-10 under the Securities Exchange Act of 1934, as amended, requires that all security
   transactions involving variable annuities and other securities be confirmed in writing to me. In lieu of receiving such
   written confirmation from Security Benefit and its underwriters, I instruct Security Benefit to forward confirmation of
   securities transactions to Advisor on my behalf. I expect the Advisor to prepare consolidated financial reports for me
   and that information concerning my investment will be included in such reports. I acknowledge by doing this, I release
   Security Benefit from any loss incurred by Advisor using this information.

7. Disclaimers
Security Benefit does not make any representation or warranty, by accepting instructions concerning the tax treatment of payment of fees under
the Internal Revenue Code of 1986, as amended, or otherwise.
Security Benefit has no responsibility or liability for any taxes, penalties and/or interest that may be assessed by the Internal Revenue Service or
other administrative tribunal or court arising out of this authorization.
I hereby release Security Benefit from any taxes, penalties and/or interest (individually and collectively referred to as “Loss”) arising out of any
Advisor-initiated transfer or partial surrender.

8. Provide Signatures

Your signature is required to authorize Security Benefit to activate this authorization.
This authorization shall remain in effect until the earlier of:
        (1) the next valuation date following the receipt of termination notice to this authorization either (a) written and
            signed, or (b) submitted electronically, by either the Owner(s)/Participant or Advisor;
        (2) the full surrender or total distribution of the Account; or
        (3) the death of Owner/Participant.
x________________________________________________________ x_________________________________________________________
  Signature of Owner/Participant                    Date (mm/dd/yyyy)           Signature of Joint Owner (if applicable)        Date (mm/dd/yyyy)

x________________________________________________________                     __________________________________________________________
  Signature of Investment Advisor Firm/Individual   Date (mm/dd/yyyy)          Print Name of Investment Advisor Firm/Individual

x________________________________________________________                     __________________________________________________________
  Signature of Representative                       Date (mm/dd/yyyy)          Print Name of Representative

                                           Mail to: Security Benefit • PO Box 750497 • Topeka, KS 66675-0497 or
                                                                   Fax to: 1-785-368-1772
                                                         Visit us online at www.securitybenefit.com
                                                                                                                                     32-77940-02 (2/2)

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