THE PENN MUTUAL LIFE INSURANCE COMPANY - Beneflex Financial Group

THE PENN MUTUAL LIFE INSURANCE COMPANY

TEXAS

Instructions for the Fixed Deferred and Single Premium Immediate Annuity Applications

This application package is broken down into 3 components:

PM1151 Annuity Application - Gathers all the required information on product, owner and suit ability information.

PM1152 Agent(s) Certification and Signatures – All agents receiving compensation must signthis document.

PM1154 Supplemental Application for the Single Premium Immediate Annuity – Gathers information for income payment mode, selection of plan type and federal income taxwithholding.

Only PM1151 and PM1152 are required for the Flexible or Single Premium Fixed Deferred Annuitysales.

All of the sections require signatures and must be submitted together as a package.

Missing information will result in processing delays. Please have the client initial above crossed out application changes. Use of white out is not acceptable.

We are unable to accept starter checks, money orders and cashier checks.

To assist you with the sale of this annuity, we have included key state required forms and additional Penn Mutual forms.

See next page for product information. Please go to Producer’s Place on the Penn Mutual Websitefor state approvals and detailed product information.

Mailing Address:

Penn Mutual Life Insurance CompanyAnnuity New Business – C2L

600 Dresher RoadHorsham, PA 19044

(800) 873-6285

PM1160(TX) Version 04/06

Fixed Deferred and Immediate Annuity Product Sheet

Single Premium Fixed Deferred Annuity• 7 year surrender schedule based on age of contract• Enhanced interest rate on first year purchase payments• $5,000 Minimum• Maximum issue age is 85 (based on age nearest birthday)• Accepts deposits in 1st contract year only

Flexible Premium Fixed Deferred Annuity• 7 year surrender schedule based on age of contract• Enhanced interest rate on first year purchase payments• $5,000 Minimum• Maximum issue age is 85 (based on age nearest birthday)• Accepts ongoing deposits

Single Premium Immediate Annuity• $2,500 Minimum• Maximum issue age is 85 (based on age nearest birthday)• Flexible Pay-Out Options• COLA benefit available on non-qualified contracts

PM1160(TX) Version 04/06

The Penn Mutual Life Insurance Company Philadelphia, PA 19172

1. PRODUCT / MARKET TYPE

Product Type:

Product Name:

Must Also Complete: FIXED DEFERRED

Type of Annuity to be Established

PM1152 PM1152 and PM1153 PM1152 and PM1154

INSERT PRODUCT NAME FROM PRODUCT SHEET

VARIABLE DEFERRED SINGLE PREMIUM IMMEDIATE

Non Qualified Individual (includes Trusts and Corporations) 1035(a) Tax Free Exchange Charitable Remainder Trust (Check Product Availability)

Type of Qualified Payment Regular Contribution ________Tax Year Transfer - Institution to Institution Rollover

* Retirement Planner Only: Group Name or #________________________Future Amount to be Billed $_________________________

Annuity ApplicationGENERIC

2. BENEFITS AND OPTIONS

LIVING BENEFITSNot available with Enhanced Death Benefit

ENHANCED DEATH BENEFITS

Available on Selected Variable Deferred Products Only

Guaranteed Minimum Accumulation Benefit Guaranteed Minimum Withdrawal, Accumulation and Death Benefit

Available on Selected Variable Deferred Products Only Optional Step-Up Plus Optional Rising Floor Plus* (Not Available on Enhanced Credit) Estate Enhancement* (Not Available with IRA)

10% Cumulative Free Option - Check Product Availability

Qualified Traditional IRA (Roth IRA not available) SEP IRA* Simple IRA* Inherited IRA/Stretch Custodial IRA 403(b) 412(i) Qualified Plan* ________________________

If any rider or benefit I have selected in this Section cannot be added to the contract due to age restriction or state availability, I understand that the contract will be issued without the benefit or rider(s).

PM1151 Page 1 of 7 Version 01/06

OTHER

*Not available in NY and WA

5. OWNER: PRIMARY OWNER: NAME

RESIDENCE: STREET CITY STATE ZIP CODE

DATE OF BIRTH: (mm/dd/yyyy) SOCIAL SECURITY / TAX ID # DAYTIME PHONE

JOINT OWNER: NAME

Male Female

Male Female

Entity

If Annuitant and Owner are the same, it is not necessary to complete this section. Joint Owners must be spouses. List both as beneficiaries in Section 7 if contract is to continue to surviving spouse.

3. PURCHASE PAYMENT: Check Product Minimums

Purchase Payment:_________________________________________________________________________________________

Estimated Amount of Exchange/Transfer/Rollover:________________________________________________________________

4. ANNUITANT PRIMARY ANNUITANT: NAME

RESIDENCE: STREET CITY STATE ZIP CODE

DATE OF BIRTH: (mm/dd/yyyy) SOCIAL SECURITY # DAYTIME PHONE


JOINT/SECONDARY ANNUITANT: NAME

Male Female

Male Female

Yes No

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/ / ( )

/ / – –

– –

( )

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6. OWNER SUITABILITY:

HOUSEHOLD INCOME LIQUID NET WORTH (Exclude Value of Residence) TAX BRACKET % U.S. CITIZEN

$ $ %

To be completed for all annuity business unless otherwise noted below.

None - No investment experience. Previous holdings were generally limited to bank savings accounts and CDs.

Average - Invests in securities on an infrequent basis. Has 1-2 years experience investing in securities. Has a general knowledge of the risks and rewards of investing in securities.

Above Average - Invests in securities on a frequent basis. Has a number of years experience investing in securities. Has a general knowledge of the risks and rewards of investing in securities.

Active - Invests in securities on a frequent basis. Has a number of years experience investing in securities. Has extensive knowledge of the risks and rewards of investing in securities.

A. Prior Investment Experience

For HTK Producers: Complete this section for Fixed Annuities ONLY. For Variable Annuities, complete the HTK Account Agreement in lieu of this section.

For Non-HTK Producers: This section must be completed for both Fixed and Variable Annuities.


6. OWNER SUITABILITY (Continued)

Please provide the anticipated holding period for the product purchased: years

Conservative-Accepts a low return potential. Maintain a low degree of risk

Moderate-Accepts fair degree of risk including lack of liquidity, in order to pursue the potential for a modest return

Aggressive-Accepts high degree of risk, including a limited loss of principal, in order to pursue the potential for a higher return

Very Aggressive-Accepts maximum degree of risk, including total loss of principal, in order to pursue the maximum possible return

B. Risk Profile

Safety of Principal –Preservation of investment Principal

Income-Regular, current income stream. May need investment principal within next five years.

Growth and Income-Moderate growth. Current Income Stream. May need investment principal within next five years

Growth-Grow assets moderately or slightly above rate of inflation. Will not need investment principal for at least ten years

Aggressive Growth-Desire to grow assets substantially. Will not need investment principal for at least ten years. Reinvestment of income

Speculation-Grow assets substantially in a short time frame. Higher than average possibility of total loss of principal. Will not need investment principal for at least ten years

C. Primary Investment Objective

D. Primary Source of Funds (for this transaction)

Current Income

Gift/Inheritance

Proceeds from sale of mutual funds

Other

Rollover from pension/retirement fund

Proceeds from sale of stocks or bonds

Policy Values from existing life/annuity contract

Surrender of life insurance/annuity contract

Savings

Personal Loan

E. Financial Needs/Benefits (check all that apply)

Death Benefit/Enhanced Death Benefit

Asset Rebalancing

Retirement Funding

Estate Planning

Tax Deferral/Tax Advantage

Savings, Accumulation

Diversification of Investments

Education/College Funding

Business Purposes

Annuitization Options

Debt Protection

Charitable Giving

Current Income

Other


8. ANNUITY DATE: If no date entered, Annuity Date will be the later of the 1st day of the month after the annuitant’s 95th birthday.

WRITE IN DATE: (mm/01/yyyy) ___ / 01 / ___

9. REPLACEMENT INFORMATION

10. REMARKS

YES NO Do you have existing annuity or life insurance contracts? (For NAIC Model Replacement States,if yes, an Important Notice Regarding Replacement Form is required - PM0479)

YES NO Will the annuity applied for replace (in whole or in part) one or more existing annuity or life insurancecontracts? If yes, please indicate carrier and contract number(s) in Remarks. For all states, if yes, a Replacement Form is required

SOCIAL SECURITY / TAX ID # PERCENT OF PROCEEDS RELATIONSHIP TO OWNER

7. BENEFICIARY: DATE OF BIRTH: (mm/dd/yyyy)

PRIMARY BENEFICIARY: NAME


DATE OF BIRTH: (mm/dd/yyyy)


CONTINGENT BENEFICIARY: NAME



DATE OF BIRTH: (mm/dd/yyyy)

CONTINGENT BENEFICIARY: NAME

If more than one, indicate whole %. List additional beneficiaries in Remarks Section. If no beneficiary is indicated, the default will be the Estate of the Annuitant. If the contract is issued to a qualified plan, the beneficiary is the Plan Trustee.

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11. FRAUD NOTICESApplies to all states except those specifically listed: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a 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.

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, and 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 the policyholder or claimant 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: WARNING It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or application containing any false, incomplete, or misleading information is guilty of a felony in the third degree.

Kentucky: 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. Massachusetts: 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.

Maine & Tennessee: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. New Jersey: Any person who includes 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 the 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.

Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds for an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Oregon: Any person who, knowingly and with intent to defraud any insurance company or other person, files an application for insurance or a statement of claim containing any materially false information or conceals for the propose of misleading information concerning any fact material may be guilty of a fraudulent insurance act which is a crime and may subject such person to criminal and civil penalties.

Pennsylvania: All applications for insurance and all claim forms shall contain or have attached thereto the following notice: "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. Virginia: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submit an application or files a claim containing a false or deceptive statement may have violated state law.

Vermont: 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 may be proven guilty of fraud.

Washington: Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of a criminal offense under state law.


12. DISCLOSURES

13. SIGNATURE(S) AND ACKNOWLEDGEMENTS

I hereby represent that my answers to the above Sections are correct and true to the best of my knowledge and belief. By signing below, I understand that: a) This annuity is a long term commitment to meet insurance needs and financial goals. The annuity applied for is suitable for my investment objectives and my financial situation and needs; b) My signature certifies, under penalty of perjury: 1) The number shown in this application as my social secruity number or taxpayer identification number is correct; and 2) I am not subject to backup withholding because I have not been notified by the IRS that I am subject to backup withholding as a failure to report all interest or dividends and, or the IRS has notified me that I am no longer subject to backup withholding, or I am exempt from backup withholding. Check this box if you are subject to backup withholding under section 3406(a)(1)(c) of the Internal Revenue Code.

DATE: (mm/dd/yyyy)PRIMARY OWNER SIGNATURE

DATE: (mm/dd/yyyy)JOINT OWNER SIGNATURE

DATE: (mm/dd/yyyy)ANNUITANT SIGNATURE (IF NOT OWNER) JOINT ANNUITANT SIGNATURE

BROKERAGE ACCOUNT # (IF APPLICABLE)

APPLICATION SIGNED AT: CITY STATE

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IRS Annuity Aggregation RulesUnder IRS regulations, all deferred annuity contracts issued by the same insurance company to the same policyholder during a calendar year are treated as one annuity contract. Under the IRS aggregation rules, all amounts received from such annuities are aggregated for tax calculation and tax reporting purposes.

Notice for Annuity Purchases in Qualified PlansThe reasons for the purchase of a variable annuity should not include tax deferral when the annuity is intended for use in a tax-qualified retirement plan such as a 401(k), IRA, SEP, or 403(b). The tax deferral is already provided by the tax-qualified retirement plan. In these situations, the reasons for the purchase of a variable annuity should focus on other benefits, such as lifetime income payments, family protection through an enhanced death benefit, multiple fund managers and guaranteed fees.

Qualified Plan/Charitable Remainder Trust Tax ReportingThe Penn Mutual Life Insurance Company will not be responsible for any administration or tax reporting for any of the contracts or policies that it issues for the Trust. The Plan Trustee will be responsible for all administration, including tax reporting, trust account-ing, calculation of trust distribution requirements, annual trust return filings, etc. The Trustee may, at his/her discretion, retain a qualified third-party administrator (TPA) to perform administration and tax reporting.

Deferred Annuity Contracts Owned by Non-Natural EntitiesDeferred annuity contracts owned by non-natural entities do not qualify for tax-deferred treatment of gains in the contract.

Section 403(b) Annuity Contract Restriction for Contract Owners under 591/2In connection with my application for a 403(b) Contract, I understand the restrictions on withdrawals from the contract or account as imposed by Section 403(b)(11) of the Internal Revenue Code. I understand that this contract is not subject to the requirements of ERISA. Further, I understand the other investment alternatives, if any, that may be available to me under my employerʼs Sections 403(b) arrangement to which I may elect to transfer my contract or account value and I understand that the same restric-tions on withdrawals would apply to such investment alternatives.


14. PRIMARY AGENT CERTIFICATION AND INFORMATION

15. HOME OFFICE AMENDMENTS AND CORRECTIONS

SIGNATURE OF AGENT PRINTED NAME OF AGENT

TELEPHONE # BUSINESS NAME BROKER DEALER OR MARKETING ORGANIZATION

This contract is replacing an existing life insurance policy or annuity contract.

This contract is not replacing an existing life insurance policy or annuity contract.

Penn Mutual Life Insurance Company Annuity New Business - C2L 600 Dresher Road Horsham, PA 19044 (800) 873-6285

Send Application, Check & Other Required Forms To:


( )

Not applicable in any state where written consent is required by law.

The Penn Mutual Life Insurance Company

1. ANNUITANT

2. PAYMENT INFORMATION

3. PLAN TYPE

4. FEDERAL INCOME TAX WITHHOLDING CERTIFICATE

ANNUITANT NAME

The first payment date will be one mode (i.e. monthly, quarterly) from the receipt of all money unless a specific date is indicated here: ______________________

Complete the following applicable lines:

A. I elect to have no income tax withheld from my annuity. (Do not complete Options B or C)

C. I want the following additional amount withheld from each annuity payment $ __________________ (You must complete Option B)

B. I want my withholding from each annuity payment to be figured using the number of allowances and marital status shown Single Married Married, but withhold at higher single rate Enter number of allowances _________________

Supplemental Application for Single Premium Immediate Annuity

Income Payment Mode:

Payments must start within one year from annuity date.

Monthly

2. Single Life Income with ________________ Guaranteed Payments

3. Life with Installment Refund Annuity (guarantees the return of premium)

4. Joint & Survivor Annuity (without Death Benefit)

5. Joint & Survivor Annuity with ____________ Guaranteed Payments

6. Annuity Certain with ____________ Payments

Cost of Living Adjustment for Non-Qualified Contracts ___________% compounded annually (Not available on Installment Refund Plan types)

Payments will reduce to __________% at the death of either AnnuitantPayments will reduce to __________% at the death of the Primary Annuitant (Joint and Contingent)

1. Single Life Income (I fully understand that I am purchasing a NO REFUND ANNUITY. There is no Death Benefit at the time of my death.)

Semi-AnnuallyQuarterly Annually

Your annuity payments are subject to Federal income tax withholding unless you elect not to have withholding apply. Your election will remain in effect until you revoke it. You may revoke your election at any time by sending Penn Mutual Life an IRS Form W-4P.

Depending on your state of residency, state withholding may be withheld if you elect B or C above.

Proof of birth is required for the first 5 plan types. Proof of birth is required for all annuitants.


5. DIRECT DEPOSIT AUTHORIZATION

6. SIGNATURES

BANK NAME

BANK ROUTING NUMBER ACCOUNT NUMBER

Checking Account (attach a voided check)Savings Account (attach a deposit slip)

DATE: (mm/dd/yyyy)PRIMARY OWNER SIGNATURE

DATE: (mm/dd/yyyy)SIGNATURE OF AGENT

The Penn Mutual Life Insurance Company (PML) is authorized to credit payments to the above account at the bank indicated. The payments are valid only if the payee is (are) alive on the payment date. I, for myself, my heirs, execu-tors, administrators and assignees do hereby agree that any sums of money deposited to my account in error, shall be refunded to PML. This authorization applies to all repetitive payments made to me (us) by PML.


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AGENT’S NAME(PRINT NAME) AGENT’S EMAIL ADDRESS

PML OFFICE CODE

(3 DIGIT)

PML REP CODE

(5 DIGIT)% OF

COMMISSIONSERVICING

AGENTINDICATE WITH X

ALL AGENTS RECEIVING COMMISSION MUST COMPLETE THE INFORMATION BELOW AND SIGN THIS FORM.

COMMISSION OPTION SELECTED FOR PRODUCTS (Choose Option 1, 2 or 3 Default is Option 1) Option 1 Option 2 Option 3

2. AGENT

3. VERIFICATION OF IDENTITIES

1. I have complied with all state licensing and educational requirements.2. I have complied with all required Commission Disclosures.3. For Fixed Annuity Sales, I have provided the client with the Disclosure and Buyer’s Guide for Fixed Annuities as required by certain state regulations.4. If a replacement is involved, all agents associated with this sale certify that replacement is in the best interests of the Contract owner.

OWNERDriver’s License Passport Birth Certificate

Other Government Issued ID

ID Number

Issuing Authority

Issue Date:

Expiration Date:

JOINT OWNERDriver’s License Passport Birth Certificate

Other Government Issued ID

ID Number

Issuing Authority

Issue Date:

Expiration Date:

Review ID and verify that the photograph on the ID is the individual. Record ID information above. If individual does not have a Driver’s License, Passport, or unexpired Government Issued photo ID, secure a copy of the individual’s birth certificate. ID information must be obtained for ALL owners. For entities (trusts, corporations, partnerships) secure the appropriate documentation (Certification of Trust, Articles of Incorporation, Corporate Resolution, Partnership Agreement)ADDITIONALY FOR ENTITIES AND TRUSTS AND PARTNERSHIPS: Please obtain ID for each Owner, Trustee, or Partner

Please complete the New Business Marketing Checklist on the back of this form.

The Penn Mutual Life Insurance Company Agents Certificationand Signatures

1. ANNUITANTANNUITANT NAME

I certify to the best of my knowledge the answers to the questions in all parts of this application are true and correct.

Agent Signature X

Agent Signature X

Agent Signature X

Agent Signature X

Agent Signature X


4. NEW BUSINESS MARKETING INFORMATION

If you used elements of any of these marketing programs or tools to support your sale please check all that apply. Penn Mutual Marketing Brochures BBP – The Business Building Partners Program BOSS - Business Owner Success Strategies Small Business, Big Mistakes Seminar Marketing Women’s Niche Marketing Program The Healthcare Niche Marketing Program Referral Marketing Email Concepts Newsletters Trade Shows

Please check the sales support services and sales concepts used to acquire the sale:

Sales Support Services Used

Marketing Consultation Advanced Sales Support Product Sales Support (Life or Annuity)

Sales Concepts

Protection (Death Benefit) Wealth Accumulation (College Funding, Retirement Savings, etc.) Retirement Planning (IRA or Qualified Plan, Retirement Distributions, etc.) Estate Planning (Estate Liquidity, Wealth Transfer, Charitable Giving, etc.) Business Continuation (Buy-Sell Agreement, Key Person, PASS/PASS Plus, etc.) Selective Employee Benefits (Deferred Comp, Split Dollar, Executive Bonus, etc.)


PM1058A

PML Fixed & Variable Annuity Suitability Questionnaire

600 Dresher Road Horsham, PA 19044

The reasons for the purchase of an annuity should not include tax deferral when the annuity is intended for use in a tax-qualified retirement plan such as a 401(k), IRA, SEP, or 403(b). The tax deferral feature is already provided by the tax-qualified retirement plan. In these situations, the reasons for the purchase of an annuity should focus on other benefits, such as lifetime income payments, family protection through an enhanced death benefit, multiple fund managers and guaranteed fees.

_______________________________ ________ ______________ Owner Signature Joint Owner Signature Date

The representative(s) certifies that the above information is correct and complete and that the client is known to the representative(s). All contract features; charges and expenses have been fully explained to the client. Additionally, the client has sufficient assets to meet short-term liquidity needs and has a long - term investment objective.

_______________________________ ___________________________________ _______________ Producer (1) Producer (2) Date _____________________________ ___ _______ Supervising Principal Date

Investment Objective (Check all that apply) 1 Safety of Principal –Preservation of investment Principal. 1 Income-Regular, current income stream. May need investment principal within next five years. 1 Growth and Income-Moderate growth. Current Income Stream. May need investment principal within next five years. 1 Growth-Grow assets moderately or slightly above rate of inflation. Will not need investment principal for at least ten years. 1 Aggressive Growth-Desire to grow assets substantially. Will not need investment principal for at least ten years. Reinvestment of income. 1 Speculation-Grow assets substantially in short time frame. Higher than average possibility of total loss of principal. Will not need investment principal for at least ten years.

Risk Profile (Check one) 1Conservative-Accepts a low return potential. Maintain a low degree of risk. 1Moderate-Accepts fair degree of risk including lack of liquidity, in order to pursue the potential for a modest return. 1Aggressive-Accepts high degree of risk, including partial loss of principal, in order to pursue the potential for a higher return. 1Very Aggressive-Accepts maximum degree of risk, including total loss of principal, in order to pursue the maximum possible return.

Primary Source of Funds: 1 Current Income 1 Savings 1 Gift/Inheritance 1 Rollover from pension/retirement plan 1 Policy Values from existing life/annuity contract** 1 Surrender of life insurance/annuity contract** 1 Proceeds from sale of stocks or bonds 1 Proceeds from sale of mutual funds** 1 Personal Loan 1 Other _________________________ ** Investor consent form or appropriate switching forms must be attached (HTK Producers Only) Financial Needs/Benefits (Check all that apply) 1 Death Benefit/Enhanced Death Benefit 1 Tax deferral/Tax advantage 1 Annuitization Options 1 Diversification of Investments

1 Asset Rebalancing 1 Charitable Giving 1 Business Purposes 1 Retirement Funding 1Savings, Accumulation

1 Education/College Funding 1 Current Income 1 Estate Planning 1 Other

Product Name: ________________________________________________________________Contract Owner’s Name: __________________________________ Date of Birth__________Owner’s Tax ID Number: __________________ Owner’s Occupation: __________________Approximate Liquid Net Worth*: ______________ Marginal Tax Bracket _____________%*Exclude home Holding Period (# of Years) __________________________ Earned Income: ____________ Unearned Income: ____________ No. Dependents: _______

Investment Experience (Check one) 1 None - No investment experience. Previous holdings were generally limited to bank savings accounts and CD’s. 1 Average-Invests in securities on an infrequent basis. Has 1-2 years experience investing in securities. General knowledge of the risks and rewards of investing in securities. 1 Above Average-Invests in securities on a frequent basis. Has a number of years experience investing in securities. Has a general knowledge of the risks and rewards of investing in securities. 1 Active-Invests in securities on a frequent basis. Has a number of years experience investing in securities. Has extensive knowledge of the risks and rewards of investing in securities.

1 I ELECT NOT TO PROVIDE THE INFORMATION NECESSARY FOR MY AGENT TO MAKE A RECOMMENDATION REGARDING THIS FIXED ANNUITY PURCHASE OR EXCHANGE. INFORMATION MUST BE PROVIDED FOR VARIABLE SALES. ________ ___________ Owner Initial Joint Owner Initial

(HOME OFFICE USE ONLY) Contract Number: _________________

PM1058A

Instructions –PML Fixed & Variable Annuity Suitability Questionnaire – PM1058A This questionnaire/supplement must be completed for ALL Penn Mutual annuity sales (fixed or variable) made to clients, who reside in applicable states. The questionnaire must be completed for the OWNER of the annuity contract.

Exemptions Unless otherwise specifically included, this questionnaire shall not apply to recommendations involving:

• Contracts used to fund: o An employee pension or welfare benefit plan that is covered by the

Employee Retirement and Income Security Act (ERISA) o A plan described by Sections 401(a) (Government Plan), 401(k), 403(b)

(TSA), 408(k) (SEP) or 408(p) (Simple IRA) of the Internal Revenue Code (IRC), as amended, if established or maintained by an employer

o A government or church plan defined in Section 414 of the IRC, a government or church welfare benefit plan, or a deferred compensation plan of a state or local government or tax exempt organization under Section 457 of the IRC

o A non-qualified deferred compensation arrangement established or maintained by an employer or plan sponsor

o Settlements of or assumptions of liabilities associated with personal injury litigation or any dispute or claim resolution process

Statement on Existing Policies or Contracts

Do you have any existing insurance policies or annuity contracts?

_____ Yes ______ No

If you answered yes above, please complete PM0479 the “ Important Notice: Replacement of Life Insurance and Annuities” form.

I certify that the above response, to the best of my knowledge, is accurate.

__________________________________________________________Applicant’s Signature Date

__________________________________________________________Producer’s Signature Date

PM0479A

PM0479TX 09/08Page 1 of 4

IMPORTANT NOTICE:

REPLACEMENT OF LIFE INSURANCE AND ANNUITIES

This document must be signed by the applicant and the producer, if there is one,and a copy left with the applicant.

You are contemplating the purchase of a life insurance policy or annuity contract. In some casesthis purchase may involve discontinuing or changing an existing life insurance policy or annuity contract. If so, a replacement is occurring. Financed purchases are also considered replacements.

A replacement occurs when a new life insurance policy or annuity contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing life insurance policy or annuity contract, or an existing life insurance policy or annuity contract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase.

A financed purchase occurs when the purchase of a new life insurance policy or annuity contract involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing life insurance policy or annuity contract, to pay all or part of any premium or payment due on the new life insurance policy or annuity contract. A financed purchase is a replacement.

You should carefully consider whether a replacement is in your best interest. You will payacquisition costs and there may be surrender costs deducted from your life insurance policy or annuity contract. You may be able to make changes to your existing life insurance policy or annuity contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing life insurance policy or annuity contract and may reduce the amount paid upon the death of the insured.

We want you to understand the effects of replacements before you make your purchase decisionand ask that you answer the following questions and consider the questions on the back of thisform.

1. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer,or otherwise terminating your existing life insurance policy or annuity contract? YES NO

2. Are you considering using funds from your existing life insurance policy or annuity contract to pay premiums due on the new life insurance policy or annuity contract? YES NO

If you answered "yes" to either of the above questions, list each existing life insurance policy or annuity contract you are contemplating replacing (include the name of the insurer, the insured or annuitant, and the policy or contract number if available) and whether each life insurance policy or annuity contract will be replaced or used as a source of financing.

INSURER CONTRACT OR INSURED ORANNUITANT

REPLACED ( R ) ORNAME POLICY # FINANCING ( F )

1

2

3

Page 2 of 4

Make sure you know the facts. Contact your existing company or its insurance producer for information about the old life insurance policy or annuity contract. If you request one, an in-force illustration, policy summary or available disclosure documents must be sent to you by the existing insurer. Ask for and retain all sales material used by the insurance producer in the sales presentation. Be sure that you are making a informed decision.

You have the right to return the new life insurance policy or annuity contract within 30 days of the delivery of the life insurance policy or annuity contract and receive an unconditional full refund of all premiums or considerations paid on it including any policy fees or charges or, in the case of a variable or market value adjustment policy or contract, a payment of the cash surrender value provided under the life insurance policy or annuity contract plus the fees or other charges deducted from the gross premiums or considerations imposed under such life insurance policy or annuity contract.

The existing life insurance policy or annuity contract is being replaced because

I certify that the responses herein are, to the best of my knowledge, accurate:The insurance producer (check one) did did not read aloud this notice to the applicant.

Applicant’s Signature and Printed Name Date

Producer’s Signature and Printed Name Date

I do not want this notice read aloud to me. (Applicant must initial only if they do not want the notice read aloud.)

A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison of the costs and benefits of your existing life insurance policy or annuity contract and the proposed life insurance policy or annuity contract. One way to do this is to ask the company or insurance producer that sold you your existing life insurance policy or annuity contract to provide you with information concerning your existing life insurance policy or annuity contract. This may include an illustration of how your existing life insurance policy or annuity contract is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare policies or contracts. You should discuss the following with your insurance producer to determine whether replacement or financing your purchase makes sense.

PM0479TX 09/08

PREMIUMS:

Are they affordable?

Could they change?

How long will you have to pay premiums on the new policy? On the old policy?

POLICY VALUES:

New policies usually take longer to build cash values and to pay dividends.

Acquisition costs for the old policy may have been paid. You will incur costs for the new one.

What surrender charges do the policies have?

What expense and sales charges will you pay on the new policy?

Does the new policy provide more insurance coverage?

INSURABILITY:

If your health has changed since you bought your old policy, the new one could cost youmore, or you could be turned down.

You may need a medical exam for a new policy.

Claims on most new policies for up to the first two years can be denied based on inaccuratestatements.

Suicide limitations may begin anew on the new coverage.

IF YOU ARE KEEPING THE OLD POLICY AS WELL AS THE NEW POLICY:

How are premiums for both policies being paid?

How will the premiums on your existing policy be affected?

Will a loan be deducted from death benefits?

What values from the old policy are being used to pay the premium?

Page 3 of 4 PM0479TX 09/08

IF YOU ARE SURRENDERING AN ANNUITY OR INTEREST SENSITIVE LIFE PRODUCT:

Will you pay surrender charges on the old contract?

What are the interest rate guarantees for the new contract?

Have you compared the contract charges or other policy expenses?

OTHER ISSUES TO CONSIDER FOR ALL TRANSACTIONS:

What are the tax consequences of buying the new policy?

Is this a tax-free exchange? (See your tax advisor.)

Is there a benefit from favorable “grandfathered” treatment of the old policy under the federal taxcode?

Will the existing insurer be willing to modify the old policy?

How does the quality and financial stability of the new company compare with the existingcompany?

Page 4 of 4 PM0479TX 09/08

Instructions to the Producer: For all sales which involve a replacement, check all product sales material which was used in making the sale, and include this form along with the other required forms when submitting the application to the home office. Do NOT use this form for NY replacements.If using a form or sales material other than those listed below, please indicate it here

PRODUCT DESCRIPTION FORM #

UNIVERSAL LIFEAccumulation Builder Consumer Brochure PM1207 Product Mechanics Brochure PMT2311 Optional Benefits and Riders PM1208BR

Guaranteed Protection UL Consumer Brochure PM1287 Consumer Kit PM1287K Optional Benefits and Riders PM1288

VARIABLE UNIVERSAL LIFE Diversified Growth VUL Consumer Brochure PM1272 Consumer Kit PM1272K Optional Benefits and Riders PM1273 Producer Product Guide PM1274

SURVIVORSHIP LIFE

Survivorship Growth VUL Consumer Brochure PM1309 Consumer Kit PM1309K Optional Benefits and Riders PM1310 Producer Product Guide PM1311

Estate Protection UL Consumer Brochure PM1189 Consumer Kit PM1189K Optional Benefits and Riders PM0717

WHOLE LIFE Flexible Choice Whole Life Consumer Brochure PM1243 Consumer Kit PM1243K Optional Benefits and Riders PM1244 Producer Product Guide PM1248

TERM INSURANCEGuaranteed Term Consumer Brochure PM120110-15-20 Consumer Kit PM1201K Optional Benefits and Riders PM1202

List of Sales Material - Life Insurance

Page 1 of 2PM0479RP 04/09

Prospectus PM1357

Prospectus PM1356

Survivorship Plus IUL Consumer Brochure PM1267 Consumer Kit PM1267K Optional Benefits and Riders PM1268 Producer Product Guide PM1269

Instructions to the Producer: For all sales which involve a replacement, check all product sales material which was used in making the sale, and include this form along with the other required forms when submitting the application to the home office. Do NOT use this form for NY replacements.

If using a form or sales material other than those listed below, please indicate it here

PRODUCT DESCRIPTION FORM #

VARIABLE ANNUITIES Enhanced Credit Consumer Brochure PM0515 Consumer Sales Kit PM0515K Prospectus Packet ENCRDPK Pennant Select Consumer Brochure PM0164 Consumer Sales Kit PM0164K Prospectus Packet PNSLPK Penn Freedom Consumer Brochure PM0728 Consumer Sales Kit PM0728K Prospectus Packet PNFREEPK Retirement Planner Consumer Brochure PM1059 Consumer Sales Kit PM1059K Prospectus Packet RTPLNRPK

FIXED ANNUITIES Single Premium Fixed Consumer Brochure PM1092Deferred Annuity Consumer Sales Kit PM1092K

Flexible Premium Fixed Consumer Brochure PM1092Deferred Annuity Consumer Sales Kit PM1092K Single Premium Consumer Brochure PM0923 Immediate Annuity Consumer Sales Kit PM0923K

MARKET APPLICATION Penn Mutual Investment Options PM0166MATERIALS Lifestyle Asset Allocation Funds PM5623 Variable Investing: An Overview PM5628 72(q) / 72(t) Distribution Options PM5549 Annuity Overview Brochure PM0955 Simple IRA EB2077 SEP IRA EB2078 412e (3) Brochure PM0982 Stretch IRA Brochure PM0825 Traditional IRA PM5429 Variable Annuities Optional PM1283 Benefits and Riders Brochure

List of Sales Material - Annuities

Page 2 of 2PM0479RP 04/09

The Penn Mutual Life Insurance CompanyThe Penn Insurance and Annuity Company

1035 Exchange/Transfer Instructions and Information

Forms needed to complete a 1035 Exchange for Life or Annuity:

PM 8297 (1035 Exchange/Transfer Request Form)PM8297A (1035 Exchange Disclosure Statement)

Form needed to complete a Transfer or Direct Rollover:

PM8297 (1035 Exchange/Transfer Request Form)

All forms MUST be fully completed, dated, and signed by the appropriate parties.

Signature of spouse is required if Community Property State:(AZ, CA, ID, LA, NM, NV, TX, WA, WI)

A separate Exchange/Transfer form must be completed for each carrier involved;multiple policies/contracts from the same carrier can use one form.

For life insurance exchanges and transfers an illustration showing the exchange must besubmitted.

Policies and contracts with Collateral Assignments must have the Assignment releasedprior to the exchange.

Irrevocable Beneficiaries MUST sign the Exchange/Transfer form in addition to theowner.

PM8297 - Instructions

Owner Name SSN/TIN

SSN/TIN

SSN/TIN

SSN/TIN

Phone #

Joint Owner Name

Insured/Annuitant Name

Joint Insured/Annuitant Name

Current Company Name (please attach a current client statement)

1. OWNER / INSURED / ANNUITANT INFORMATION (please print)

2. RETURN OF CONTRACT OR POLICY

The Penn Mutual Life Insurance CompanyThe Penn Insurance and Annuity Company600 Dresher RoadHorsham, PA 19044Customer Service Center: 800-523-0650

1035 EXCHANGE /TRANSFER REQUEST FORM

Street Address (PO Boxes are not permitted)

City State Zip

Contract(s) / Policy Number(s) being exchanged / transferred

3. CURRENT POLICY / CONTRACT INFORMATION (please print)


If you are transferring the full value of your current contract or policy, you must attach the contract or policy pages to this form. If you do not have a contract or policy, please check the reason below.

The contract or policy was lost or destroyed

Full Value

Partial Value in the amount of $ or % of my present account (annuity only)

Maximum amount without penalty (annuity only)

A contract or policy does not exist for the account that is being transferred (i.e., CD, Mutual Fund)

I hereby request the Liquidation and Transfer of the above listed contract / policy number(s) for the:

New Life Policy

New Annuity Contract

Existing Penn Mutual Annuity Contract # (annuity only)

Transfer / Rollover / Exchange the proceeds to a:

I understand I will incur a penalty of: 0% or % totaling $ by liquidating the requested amount.

Transfer the proceeds: Immediately or Specific date

OPTION A: 1035 EXCHANGE

My present account is a:

The required state replacement form(s) must accompany this request

OPTION B: TRANSFER OF NON-QUALIFIED FUNDS


Mutual Fund CD Individual Account Other

4. TRANSFER AND / 1035 EXCHANGE ELECTION (please select only one option)

OPTION C: TRANSFER OR ROLLOVER OF QUALIFIED FUNDS (Trustee to Trustee)


Required Minimum Distribution status for the current tax year: (if applicable)

Surviving spouse beneficiary of deceased annuitant

Former spouse receiving distribution under a Qualified Domestic Relations Order “QDRO”. **To process, we require a copy of the QDRO.

If you are neither the Owner nor the Annuitant of the existing contract, check where applicable below:

Traditional IRA SEP - IRA Simple IRA Inherited Stretch IRA

401(a)

Other Retirement Plan

RMD has already been satisfied RMD has not been satisfied. Please process before transfer

401(k) 403(b) (with triggering event) 457(b) Governmental


LOAN ELECTION:

I request that any loan(s) on my existing Life Insurance Policy(s) be:

Carried over to the new policy

Extinguished during the exchange Note: this may trigger a taxable event

Loans being carried over to the Accumulation Builder Flexible Premium Adjustable Indexed Life Insurance Policy must elect an interest option below to apply to the transferred loan.

Traditional Loan Option: Loan is first deducted from the Fixed Account, then from the Holding and Indexed Accounts. This loan option credits an interest rate equal to the policy loan rate that is charged on the loan amount after the first 10 policy years. The credited loan interest rate is decreased by 1% for loans taken out in the first 10 policy years.

Indexed Loan Option: Available only in the cash surrender value in the Indexed Account segments. The outstanding loan amount continues to earn an interest rate based on the indexed credit for the segment(s) from which the money was borrowed. The cost of the loan is the difference between the declared variable loan rate charged and the indexed credit for mature account segments. If there is not enough money in the indexed account to cover the loan, funds must be transferred from the Fixed Account on the segment date in order to take the full loan amount. However, there is a risk that the interest rate credited can fall below the rate being charged on the loan - but never less than the 2 percent floor.

Life Insurance Policy Fixed Annuity Variable Annuity Endowment

5. AUTHORIZATION - Select the same option as page two (a signature guarantee may be required)

6. ACCEPTANCE OF TRANSFER/ROLLOVER / 1035 EXCHANGE (Home Office use only)


OPTION A - ABSOLUTE ASSIGNMENT AND EXCHANGE REQUEST BY CONTRACT OWNER

I hereby absolutely assign all rights, title and interest in the contract(s) listed above, without exception, limitation or reservation, to The Penn Mutual Life Insurance Company or The Penn Insurance & Annuity Company (hereinafter referred to as “The Company.”) Further, I hereby revoke all prior beneficiary designations and designate The Company as the sole beneficiary of the existing contract. I hereby authorize The Company to forward a copy of this Absolute Assignment and Exchange Request to the issuer of my current contract(s). I certify that there are no other assigments on said contract(s) and that no petition in bankruptcy has been file by or against me.

I expressly represent that the sole purpose of this assignment is to affect an exchange of a life insurance, endowment or annuity contract under Section 1035 of the Internal Revenue Code. I acknowledge that Penn Mutual is furnishing this form and is participating in this transaction at my specific request as an accommodation to me.

I request that The Company, upon satisfaction of its underwriting requirements, surrender the existing contract(s) for the full or partial cash value of said existing contract(s) and immediately upon receipt of surrender amounts and as part of the same transaction, apply all surrender amounts received to the Company contract. I understand that after The Company submits the request for surrender of the existing contract(s) to the current issuer and the surrender is processed by the current issuer, such contract(s) will no longer be in force and effect and that the designated beneficiaries cannot receive the proceeds from such contract(s) in the event of the death of the insured, or in the case of an annuity, the annuitants or contract owner.

OPTION B OR C - REQUEST FOR TRUSTEE-TO-TRUSTEE TRANSFER OR DIRECT ROLLOVER

I hereby direct the current institution to convert to cash the assets held for the owner in the account and to transfer this money to The Company. I have completed an application for a Life Insurance policy, Annuity contract or have an existing Annuity contract to receive the transferred money. I understand that The Company assumes no responsibility for tax treatment of this matter and I shall be responsible for payment of all federal, state and local taxes incurred with respect to the liquidation of the account. (If the existing contract(s) is funding a qualified plan, ownership of the existing contracts(s) is not transferred by this Absolute Assignment and Exchange Request.)

You hereby certify that you have read and understand the terms of this form and that the information provided on this form is true and complete to the best of your knowledge.

Owner Signature Date

Other Signature (if applicable) (e.g., joint owner, co-trustee, irrevocable beneficiary, Dateor spouse, if Community Property State, etc)

Title (Required if the owner is a trust, custodian, partnership or corporation)

Signature Guarantee (If applicable)A separate guarantee is needed for each signature.

We request the liquidation and transfer of the account listed in Section 3. By our signature below, we represent that the account described is or is intended to be an account of the type indicated and that we will accept the Section 1035 Exchange/Transfer on behalf of the person(s) named on this form. Please provide us with the Pre and Post TEFRA Cost Basis in the current policy/contract, if applicable.

Authorized Officer Signature

Title Date

1035 EXCHANGE DISCLOSURE STATEMENT

Generally, the surrender of an existing insurance or annuity contract is a taxable event; the contract owner mustrecognize any gain on the original, surrendered contract as current income. IRS section 1035 provides a tax-freemethod of exchanging an existing life, endowment or annuity contract for a new contract. If the exchange meets the conditions of Section 1035 of the Internal Revenue Code, the transfer will be a non-taxable event.

No limit is imposed on the number of contracts that can be exchanged for the one contract. However, allcontracts must be on the same insured and have the same owner. Changes in ownership may occur after theexchange is completed. The contracts must be life insurance, endowment or annuity contracts issued by a lifeinsurance company. Exchanges must be: from a life insurance contract to a life insurance contract; from a lifeinsurance contract to an annuity contract; from an endowment contract to an annuity contract or from an annuitycontract to an annuity contract.

For a transaction to qualify as a 1035 Exchange, the original contract must actually be exchanged for a newcontract. It is not sufficient for the policy owner to receive a check and apply the proceeds to the purchase of anew contract. The exchange must take place between the two insurance companies. Receipt by the policy ownerof any portion of the surrender proceeds from contracts being exchanged may be treated as a taxable event. Thisincludes outstanding policy loans extinguished during the exchange process.

The policyowner has several ways to deal with an outstanding loan on the original life policy. The loan can beextinguished or canceled at the time of the exchange. If there is a gain in the contract, cancellation of the loan onthe original policy is considered a distribution and may be a taxable event. To avoid this result, the policyownercan pay off the existing loan prior to the exchange. A second way of avoiding a taxable event due to the loanwould be for the old loan to be carried over onto the new contract.

Life insurance contracts issued before June 21, 1988 may lose preferential tax treatment afforded them underInternal Revenue Code Section 7702 and 7702A under certain circumstances in a 1035 Exchange. The new policymay be classified as a modified endowment contract (“MEC”)and taxed accordingly. Most single premium lifeinsurance policies issued after June 21, 1988 are characterized as MECs. If two or more policies are exchangedfor a single contract and at least one of the existing contracts is a MEC, the new policy will also be a MEC.

The contract owner must indicate that a Section 1035 Exchange is being initiated at the time the new applicationis completed. The policy owner and the Internal Revenue Service will receive an Internal Revenue Form 1099Rfrom the original company indicating that an exchange has been made.

For Annuity Contracts only, you should be aware that some insurance companies do not recognize partial 1035 exchanges. If you are partially exchanging into Penn Mutual/PIA, your existing annuity issuer (the tax reporting agent for the transaction) may report your partial exchange as a taxable event to the extent of any gain distributed; they may also report that the taxable portion of thedistribution is subject to a 10% early withdrawal penalty. If this occurs, it will be your responsibility to claim this transaction as a tax-free 1035 exchange on your income tax return.

The foregoing discussion is general and is not intended as tax advice. Your independent tax advisor should beconsulted for more complete information. This discussion is based on the Company’s understanding of federalincome tax laws as they are currently interpreted by the Internal Revenue Service. Penn Mutual makes norepresentations or guarantees and assumes no liability with regard to the tax consequences of this exchange.

I hereby acknowledge that I have received, read and signed a copy of the above“Section1035 DisclosureStatement”andfully understand the importance of correctly determining the tax status of all policies to beexchanged as well as the possible tax consequences which can result under the situations described above.

Dated at ____________________________ this ________ day of __________________, 2__________

Signature of Contract Owner

THE PENN MUTUAL LIFE INSURANCE COMPANYTHE PENN INSURANCE AND ANNUITY COMPANY

PM8297A 08/08

THE PENN MUTUAL LIFE INSURANCE COMPANY - Beneflex Financial Group

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