42923LTC 05/16/18
D. TRANSFER AGREEMENT
1035 Exchange and LTCI Premium Payments
I/We understand that the above requested transfer of funds from my/our existing annuity contract will be handled as a 1035 exchange. I/We hereby
authorize Genworth to request the required exchange, withdrawing the requested funds from the above designated annuity contract(s) to fund the
premiums of the Long Term Care Insurance Policy referenced above.
Other than the owner(s) mentioned herein, no person, firm or corporation, other than me and the issuing insurer, has an interest in said contract. No
proceedings in insolvency or bankruptcy have been instituted by or against me.
I/We also understand and agree that the requested withdrawals will occur automatically until I/we notify Genworth that I/we wish to terminate the
withdrawals. I/We understand that, unless otherwise designated in the Payment Options section above, the automatic withdrawals will occur even
if the annual withdrawal limit is exceeded and surrender charges may be incurred. If such surrender charges are incurred, they will be subtracted
from the contract value. I/We expressly represent that the sole purpose of this transaction is to effect an exchange of an annuity contract under
section 1035(a) of the Internal Revenue Code. I/We understand that I/we should contact an independent tax and legal advisor for advice regarding
the tax treatment of this exchange.
In the event that the requested 1035 exchange reduces the annuity contract value below stated minimums, then a full transfer of the remaining
contract value funds will occur. Any excess funds will be refunded or applied to future Long Term Care Insurance premiums due. In such an event,
I/we hereby assign and transfer without exception, limitation, or reservation to the Insurer, all assignable benefits, interest, property and rights in
the contract referenced herein. I/We understand that by executing this assignment, I/we irrevocably waive all rights, claims and demands under the
assigned contract. I/We understand that the Insurer will not treat this assignment as the equivalent of a cash payment. I/We further understand that
no part of the value of the assigned contract will be treated as a premium/purchase payment until it is received by the Insurer.
For Fixed Index Annuity contracts with the Income Protection Rider, withdrawals in excess of the guaranteed withdrawal amount, called “excess
withdrawals”, will result in a permanent reduction in future guaranteed withdrawal amounts. If you would like to make an excess withdrawal and
are uncertain how an excess withdrawal will reduce your future guaranteed withdrawal amounts, then you may contact us prior to requesting the
withdrawal to obtain a personalized, transaction-specific calculation showing the effect of the excess withdrawal.
Caution: Effecting an exchange of your annuity contract may adversely affect your rights and benefits including, potentially reducing death
benefit and living benefit values. Please discuss with your Financial Professional and refer to your contract for a description of these rights
and benefits. Prior to engaging in a 1035 exchange, you should carefully consider a number of factors including the impact to the features
and provisions of your current product, and any applicable surrender charges associated with this exchange.
Owner name Street address City State Zip code
Social Security number Date of birth mm/dd/yyyy
Joint owner name If applicable Joint owner Social Security number If applicable
Institution name Street address City State Zip code
Telephone number Annuity contract number
Estimated contract value
$
C. ANNUITY CONTRACT INFORMATION
Page 2 of 3
B. EXCHANGES TO FUND EXISTING LONG TERM CARE INSURANCE POLICY
○ I am funding an existing Genworth Long Term Care Insurance policy number:
Policyholder name Joint Policyholder name If applicable
Please print Please print
Premium information
Premium due date (mm/dd/yyyy)
Premium to transfer: $ Transfer amount should not exceed LTCI annual premium
Payment method requested
○ Withdraw from the Genworth Annuity each year for a fixed dollar amount of $
and bill me for the difference, if any.
○ Withdraw from the annuity for a fixed dollar amount of $
and bill me for the difference, if any.
○ This is a one time exchange. Apply the full annuity account value (estimated to be $ ) to my policy. Cannot exceed 2 year’s premium.
Note: Automatic annual withdrawals will be scheduled to occur on or prior to the regular premium billing date to ensure timely
payment of premiums and to permit billing of the policyholder for any balance due on their normal billing schedule. Surrender charges and other
charges may apply.