FREEDOMFLEX CANCELLATION REQUEST

Insured's Name - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Owner's Name if Different - - - - - - - - - - - - - - - - - - - - - - - -

Policy Number - - - - - - - - - - -

Date of Request - - - - - - - - - - -

Insured's Social Security Number - - - - - - - - - - - -

Insured's Address - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Agent's Name - - - - - - - - - - - - - - - - - Code# _ _ _ _ _ _ _ __

Please cancel my FREEDOMFLEX policy as of the paid to date. My agent has discussed the
possible effects of cancellation with me, and I am aware of the consequences of canceling my
FREEDOM FLEX plan. I understand that by cancelling this valuable plan I will no longer be
insured and will be eliminating my opportunity to accumulate attractive cash values. I am
cancelling my plan because: - - - - - - - - - - - - - - - - - - - - - -

If there is an active annuity account containing funds, I am also providing a completed and
signed W-9 form with this request.

Insured/Owner Signature(s) Date