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HomeMy WebLinkAbout07-6648It IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA WASHINGTON NATIONAL INSURANCE COMPANY, Plaintiff, V. BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower, Defendants. CIVIL ACTION- EQUITY CASE NO. 67 - b(oy$ Civil lerm NOTICE TO DEFEND YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the foregoing pages, you must take action within twenty (20) days after this Complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. YOU MAY LOSE MONEY OR PROPERTY OR OTHER RIGHTS IMPORTANT TO YOU. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YO DO NOT HAVE OR KNOW A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania Phone (717) 249-3166 am NOTICIA USTED HA SIDO DEMANDADO EN LA CORTE. Si usted desea defenderse de las quejas expuestas en las paginas siguientes, debe tomar accion dentro de veinte (20) dias a partir de la fecha en que recibio la demanda y el aviso. Usted debe presentar comparecencia escrita en persona o por abogado y presentar en la Corte por escrito sus defensas o sus objeciones a las demandas en su contra. Se le avisa que si no se defiende, el caso puede proceder sin usted y la Corte puede decidir en su contra sin mas aviso o notificacion por cualquier dinero reclamado en la demanda o por cualquier otra queja o compensacion reclamados por el Demandante. USTED PUEDE PERDER DINERO, O PROPRIEDADES U OTROS DERECHOS IMPORTANTES PARA USTED. LLEVE ESTA DEMANDA A UN ABOGADO IMMEDIATEMENTE. SI USTED NO TIENE O NO CONOCE UN ABOGADO, VAYA O LLAME A LA OFICINA EN LA DIRECCION ESCRITA ABAJO PARA AVERIGUAR DONDE PUEDE OBTENER ASISTENCIA LEGAL. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania Phone (717) 249-3166 41 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA WASHINGTON NATIONAL INSURANCE COMPANY, CIVIL ACTION- EQUITY Plaintiff, V. CASE NO. BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower, Defendants. COMPLAINT FOR EQUITABLE INTERPLEADER AND NOW, THIS 31 st day of October, 2007, comes now the Plaintiff, Washington National Insurance Company (hereinafter referred to as "WNIC"), by and through its counsel of record, Douglas P. France, Esquire, and for its Complaint for Equitable Interpleader, alleges as follows: 1. WNIC is a foreign insurance corporation doing business in the County of Cumberland, State of Pennsylvania, on a continual basis at all times pertinent hereto. 2. Defendant Barry Beinhower is an adult individual with a last known address of 285 Big Springs Road, Etters, York County, Pennsylvania 17319. 10 3. Defendant Nancy Rogowicz is an adult individual with a last known address of 555 Hillcrest Road, York, York County, Pennsylvania 17403. 4. Defendant Courtney Myers is an adult individual with a last known address of 555 Hillcrest Road, York, York County, Pennsylvania 17403. 5. Defendant Nancy Beinhower is an adult individual with a last known address of 7 Columbia Drive, Camp Hill, Pennsylvania 17011. 6. Defendant Terry Cassel, Executrix of the Estate of Clair Beinhower, is an adult individual with a last known address of c/o Jacqueline Welby, Esquire, 3511 North Front Street, Harrisburg, Pennsylvania 17110. 7. On March 17, 2007, there was in existence a flexible premium deferred index annuity, policy number VAR002347 (the "Annuity") issued by WNIC to Clair Beinhower ("Annuitant"). A true and accurate copy of the Annuity is attached hereto as "Exhibit A" and incorporated herein by reference. 8. The Annuity provided a death benefit of $36,585.85 payable upon the death of the Annuitant ("Annuity Proceeds"). 9. The original beneficiary designated in the Annuity Application submitted to WNIC and dated July 25, 2006 (the "Annuity Application") identifies Annuitant's wife, Nancy F. Beinhower, as the beneficiary of the Annuity. A true and accurate copy of the Annuity Application is attached hereto as "Exhibit B" and incorporated herein by reference. 10. Pursuant to a Power of Attorney dated March 6, 2007 ("Power of Attorney"), Annuitant's son, Barry W. Beinhower, was appointed as Agent of Annuitant ("Agent"). A copy of the Power of Attorney is attached hereto as "Exhibit C" and incorporated herein by reference. 11. On or about March 15, 2006, the Agent submitted a Customer Service Form to WNIC, purporting to change the beneficiaries of the Annuity as follows, with the beneficiaries to receive "equal shares": Name Nancy J. Rogowicz Courtney (sic) N. Myers Barry Beinhower Relationship to Annuitant% Allocation Step-Daughter 33% Granddaughter 33% Son 33% A copy of the Customer Service Form is attached hereto as "Exhibit V and incorporated herein by reference. 12. On or about March 17, 2007, the Annuitant died in Cumberland County, Pennsylvania. A true and accurate copy of the Annuitant's's Death Certificate is attached hereto as "Exhibit E" and incorporated herein by reference. 13. WNIC has received an Annuity Claimant Statement dated April 26, 2007 requesting payment of the Annuity Proceeds to Nancy Rogowicz, the Annuitant's step- daughter. A true and accurate copy of this Annuity Claimant Statement is attached hereto as "Exhibit F" and incorporated herein by reference. 14. WNIC has received an Annuity Claimant Statement dated April 25, 2007 requesting payment of the Annuity Proceeds to Courtney N. Myers, the Annuitant's granddaughter. A true and accurate copy of this Annuity Claimant Statement is attached hereto as "Exhibit G" and incorporated herein by reference. 15. WNIC has received an Annuity Claimant Statement dated April 6, 2007 requesting payment of 331/2% of the Annuity Proceeds to Barry W. Beinhower, the Annuitant's son. A true and accurate copy of this Annuity Claimant Statement is attached hereto as "Exhibit H" and incorporated herein by reference. 16. WNIC has received a claim from Terri Cassel, Executrix of Annuitant's estate, requesting payment of the Annuity Proceeds to Nancy Beinhower, Annuitant's widow. In addition, Terri Cassel is challenging the validity of the beneficiary change which was made by the Agent two days prior to Annuitant's death. Correspondence from Jacqueline Welby, attorney for Terri Cassel, is attached hereto as "Exhibit I" and incorporated herein by reference. 17. WNIC is and has been prepared to distribute the Annuity Proceeds since becoming aware of the death of the Annuitant. 18. WNIC has at no time denied liability with respect to the sum of 36,585.85, which represents the total death benefit due and payable under the Annuity. 19. WNIC has at all times admitted liability and has stood ready, able, and willing to make immediate payment to the party or parties entitled to payments. 20. Because of the adverse claims to the Annuity Proceeds, WNIC is in a position of stakeholder with respect to the Annuity Proceeds. 21. WNIC cannot make payments to any interested party without being subjected to possible multiple liability and multiple litigation. 22. WNIC hereby, stands ready, willing and able to tender its check totaling $36,962.46, representing Annuity Proceeds with interest through September 1, 2007 to the Prothonotary of the Cumberland County Court of Common Pleas. A Copy of WNIC's check is attached hereto as "Exhibit X and incorporated herein by reference. 23. WNIC has been forced to incur costs and fees to Interplead the Annuity Proceeds through no fault of its own and, pursuant to the applicable law, should be allowed to recover its costs and fees from the Annuity Proceeds. WHEREFORE, Washington National Insurance Company, prays as follows: a. Upon proper hearing, WNIC be discharged from all liability to any claimants of the death benefits under the Annuity relating to the death of Clair W. Beinhower; and b. Barry Beinhower be ordered to appear and answer and to set up whatever claims he may have in and to the above referenced death benefits; and c. Nancy Rogowicz be ordered to appear and answer and to set up whatever claims she may have in and to the above referenced death benefits; and d. Courtney Myers be ordered to appear and answer and to set up whatever claims she may have in and to the above referenced death benefits; and e. Nancy Beinhower be ordered to appear and answer and to set up whatever claims she may have in and to the above referenced death benefits; and f. Terri Cassel, Executrix of the Estate of Clair Beinhower, be ordered to appear and answer and to set up whatever claims she may have in and to the above referenced death benefits; and • It g. The Court make such judgement as is necessary, including an award of WNIC's reasonable fees and costs, to determine who is properly entitled to the death benefits and release the death benefits in accordance with that judgement; and h. The Court decree that the $39,962.46 representing the Annuity Proceeds, to hold, be tendered to the Prothonotary until the proper beneficiary or beneficiaries are determined; and i. The Court take such other steps as necessary to facilitate and grant such additional relief as is right and proper in the premises. Respectfully Submitted: EN, MACDOM?lzp & FRANCE, P.C. Attorney l@-Wo. 48744 2675 Eastern Blvd. York, PA 17402-2905 Phone: (717) 757-4565 VERIFICATION I, DOUGLAS P. FRANCE, Esquire, do hereby verify that I am the attorney of record for the pleading party herein, and that the facts set forth in the foregoing Complaint are true to the best of my knowledge, information and belief, upon information supplied by Plaintiff. The verification of Plaintiff could not be obtain in a timely fashion (in order to prevent expected harm towards the Plaintiff). I understand that false statements made herein are made subject to the penalties of 18 Pa.C.S.A. §4904 relating to unsworn falsification to authorities. KAGEN, MACDONALD & FRANCE, P.C. Dated: iO 3i 10'7 BY: Douglas P. nce, Esquire Supreme Court I.D. 48744 2675 Eastern Boulevard York, Pennsylvania 17402 (717) 757-4565 Exti?bit /-1 W-20-2007 TUE OS:31 AH FAX N0, P. 02 04B688CF.HCJ App&srwa ifi made to Wn Wngwa Nadand bsw moo Lampsay ("tea Camay") I ' flame Office: CM200r Mttols Adm'mistnare OliFira: lba Olfiee Box 71173; San l Yaosisco, CA 441204173 ANNUM AMICATION PLxAsx pltt.*i'rANn M DARK ]milt: ONLY i 9 J T 2 ; .G .1 ;7 A 7 f SMCT10T1 I TUA rxu ainu?. v Joint AmMOUt (ttotapprft" n gwtliiied cWaiMds) Rlmety Aatswltaat Nom i a dairod and ) Naaora (prbit as drained Oa eontss F ; Lou vow Bowie Lst A4drau ?O? a Address ri.as4 O ' 17012- 70i Stoc+ee S CRY 74P litota zip city (o (r- T4ltpdtotae ?? 3 __ t ) TOW UM crndtir MMala ( I Pall: Gander [ a Nab [ 1 YOMOC Sotaol Se(cositY Iqumber a ''? ?"- Social Seeosr Number ?' r i Dete afBk& slis St=to` ". ! otBa? ?? ? 8 Sfe?e _ Ma Pay J& Dsy Yr Mutw Stehn s Mantel Satan Owner (ff oww No test. kdM6e ==O *Rd data) - [) Awat Ow er (asnsi be q MM" an[Owaer) s? alVAcoble to qualified cantt ww) Name NM Bisss I&"a iACt Pmt ilrYiddk tart Addtt:ss Addrnea S1rA0C slued ?y stm zip CIV State 20 Telepbom e C ? 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NoRaa Naas % x s WrAL INSTRUCWNS i? oFIPIr? c?1Nc3>os '?'kt.?itraenrridf swill willaotseplsoelusatsoeaoraotaaul wlt6 eom I I(Wa) um6w*md tbst the Cwapnpp? wM hmcst id esaa?at aeoaeod at?aets st Dolt: disccctian su+i »o aas will ba<ve ebe rig6it to direct the ahoy ccmww og the bra tnaeats owned by t Cmspu . 72m Pm&= h u ao +ut%miry to mak. mo ft, abler or discbmp my eonbut. Aocgmm of may Gomm WWA on this applic8tioa wilt ru* "as paced by tfas COeupaW In the tp " dtled -96me WSW ate" and ¦ copy of as cbuipd appliswtion attnr?ed to tits oMUW will be U icia n t aetiaa of thma rbapso. I(Va) h cm* i aulkpis+a sod dbed das Compavy m soogat and am cm =W and AU taloome treaslls. widtd mwsk Um orsavinc igtd¢md ms *am aqy I penoa wko eao fitraieh proper Wndfiesda?, including tit U64 Seem* Nun*= or Taos lb Wmnt m and pained umtdq, code afa s Owner. 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Q) do Social Swab or'! u W N shows on this ePpliMrdon 60") ceacct and ¢) l(WO) saa(pro) teeporarible far payment of Fedeyt and/or Seta Im.oane Tar as lire tatxmbk 4 pW= of w?i , ti anon. and tie I(we) asy be Sc4od W in pan Mm wader esdmuW ux pe{ycae d rda if my(om) p%mftu of 7 sattn+sbed Dot sad tax widaboidhtg, if my, ate not w6m, qc. my p=m who immvhwiy aml with iotmat m dAmd Day 6a>s sum cm*ao V or adw paam film ma app kakw Iv bxm mm arapmment or abm oonts>vas Day mataiWW rats iaara ma lm ar eaoaa,& ror the wpm* o[m ossl%u- i %ozu tam eanceo teg say fict maredal t AMD rommilsa ?audulga tCt, is a. alms and adljceb: awfa p?aasia to odaaaiuslasd oivH 1)ato , _ ,_ 7. ?? O ri Mao" 'or .r- jai, Ag ., --., 20vubm: orovam Sl?satlntt ofloiatt?wtter is not a na wal parsed, !?ritdaaae (ea, MmName and 'rlstat Date) (a.q., , Trnsace 3lpaattus, Tmx t) -MIC of Amhodg orOwner UOt m a Got Aa a awa peraca, sfpastaam orvvhrwy Annnitast higaaw= of Joint Ananipmt does not erPiara or A n mtir bast ofmy mawladge, this WplicOm I I dam rVIOD or chop 3tfe Dar I atraet • ALL STATE LEGAL SUPPLY CO.. 1-8W-122-(1510 ED I1 WASHINGTON NATIONAL INSURANCE COMPANY Horne Qfllce: Chicago, Illinois Administrative Office: Post Office Box 7873, San Francisco, California 94120-7873 • Telephone (877) 549-7663 (Toll Fret:)) FLEXIBLE PREMIUM DEFERRED ANNUITY CERTIFICATE NOTICE OF 10 DAY RIGHT TO CANCEL CERTIFICATE. No latex than ten (10) days after this Certificate is delivered, the Owner may cancel h by rt turnft this Certificate with a wtitien requcsl to cancel, to the Company's Administrative Office. Upon delivery of this Certificate and written request to cancel, axis Certificate shalt be void from the beginning. The Company will refund all premiums paid within fifteen (15) days sAer this Certificate and the written request to cancel art: received at the Corupanyy's Adtainistrative Office. Washington National lnsarance Company (hereinafter "the Company") will make the paynicats and provide the benefits described in this Certificate in consideration for the payment by the Owner of pretrtiunz. This Certificate is issued in consideration of the Application and payment of the premium(s) as described within this Certificate. TWs Certificate is a legal Contract between the Owner and Washington National Inuarance Company. Only the Company's President, Vice President, or Secretary has the authority to: (1) cbeage this Certificate; (2) extend the time for payment orpremiurns; or (3) waive any Certificate provisions. No agent has the authority to waive or changc,aoy provision of this Certificate. This Certificate provides for Crediting Rate Strategies. Tim available Crediting Rate Strategies are described in the Ir attached Endorsements. .z v Signed for the Company on the Effective Date. ?-' Secretary President !_n ._j --•r F1.F.MILE PREMIUM DEFERRED ANNUITY CERTIF] CATE ?*%I-PARTICIPATING NO ANIN'UAL DIVIDENDS Tats Certificate contains a Confinement Waiver pravision. This provision does not apply if an Owner or Annuitant (if the Owner is an entity) Is confined in a Hospital. Rospice Facility or Natrsing home on the Ccrt ocau EIl'ective Date. This is a icgal contract between the Owner and the Company. Please read this Certificate carefully. WHIG GMIA 1205-0 _ 1? Ln ^J I.J Irt1 TABLE OF CONTEhM DATA PAGE 3 ANNUITY AND SURBEYDER VALUES DEFIIVMONS 6 Strategy Value CFJ%'ERAL PROVISIONS 8 8 Annuity Value Mininwm Cmmnterd Sttrreader Value This Certificate Effective: Date 8 Surrender Value tncontestabilrty 8 W ithdraw*s Misgatiments 8 8 Surrender Market Value Adjustments Adtnintstrative Error 8 Surrender Chargcs Owner Beneficiary 9 Su render Charge-Free Widtdmwal Death Benefit 9 Confinement Waiver Proof of Death 9 SETTLEMENT OPTIONS Death Before the Maturity Date 9 Benefit Amount Death After the Maturity Dare 10 When Payments Begin Maturity Date 10 Supplementary Contracts Authority to Change 10 Minimum Scttlerntmi Option Payments Income Tax Qualification 10 Settlement Options Laws to Age Adjustments Nonparticipating 1 I Other Forms of Payment Periodic Reports 1 I What The Company May Need PREMIUMS AND CREDITING RATE GUARANTEED ANNU rrY DATES AND TABLES STRATEGIES 21 Premiums I I Crediting Rate Strategies I I II 11 12 12 12 12 12 13 13 14 14 14 15 15 IS 16 16 16 17 WHIC-GCEIA-1205.0 z Washington National Ins>srance Company Flexible Premium Deferred Index Annuity Certificate DATA PAGE Annuitant: Clair W. Beinhower"" 7 Columbia Drive Camp Hill, PA 17011.7634 Owner: Clair W.-Beinhower"' 7 Columbia Drive Camp Hill, PA 17011-7634 Beneficiary: As stated in the copy of the Application attached to this Certificate, unless subsequently changed in compliance with this Certificate`s provisions. Benefit Description: Flexible Premium Deferred Index Annuity Qualified Type; 1 1a06 Certificate Number VAR110(12347 I.Wic, Daft: Initial Premium: 536,580 Effective Date: 10/2612006 'a) Issue Age: 74 T Crediting Rate Strategies Strategy Name Allocation Percentage u S&P 500 Index One-Year Monthly Averaging With Cap Strategy 10tl:OO% w The Minimum Guaranteed Interest hate is an annualized interest rate of 3.006. s For the S&P 500 Index One-Year Point-To-Point Vilitb Cap Strategy, the Minimum Cap is A. For the S&P S00 Index One-Yeer Point-To-Point With Participation Rate Strategy, the Minimum Participation Rate is 30%. For the S&P 500 Index One-Year Monthly Averaging With Cap Strategy, the Minimum Cap is 4.009A. Surrender Charge-Free Withdrawal Percentage is 10%. •.t .,Q "Standard & Pooe's 500' is a trademark of The Mr-Gmw-Hill Companies, Inc. and has been licensed for use by Conseco Services. L.L.C. and its affiliates. This Product is not sponsored, endorsed, sold, or promoted by Standard & Pooes and Standard & Pooes makes no representation regarding the advisability of purchasing this Product. WNIC GCEIA-1205-0 DATA PAGE Washington National Insurance Company Flexible Premium Deferred Index Annuity Certificate Certificate #: VAR0002347 initial Premium: 536,580.00 Issue Age: 74 TABLE Up' GUARANTEED VALUES •Z) ?.n ,.a 'V n? Qualified Issue Date: I W2612&* Effective Date: 1012612006 Maturity Date: f 02612027 Minimum fend End of Guaranteed of Year Annuity Surrender Death Year A Value Value Benefit 1 74 36,580 32,968 36,580 2 75 36,580 33,957 36,580 3 76 36,580 34,975 36,580 4 77 36,580 36,025 36,580 5 78 36,580 37,105 37,105 6 79 36,584 38,219 38,719 7 60 36,580 39,365 39.365 8 81 36,580 40,546 40,546 9 82 36,580 41,763 41,763 10 83 36,580 43.015 43,015 11 84 36,580 44,306 44,306 12 85 36,580 45,635 45,635 13 96 36,580 47,004 47,004 14 87 36,580 48,414 48,414 15 88 36,580 49,867 49,867 16 89 36,580 51,363 51.363 17 90 36,580 52,904 52,904 18 93 36,580 54,491 54,491 19 92 36,580 56,125 56,125 20 93 36,580 57,809 57,809 21 94 • 36,580 59,543 59,543 All values are based on the Initial Premium and the Crediting Rate Strategy allocations shown on the Data Page. The values assume! . ,r there are no additional Premium Payments, Transfers, Withdrawals or Market Value Adjustments. For the purpose of this illustration, it is assumed all Premium Payments received prior to the I.tsue Date were applied to this Certificate on the Certificates Effective Date_ Guaranteed values arc based on the guarantees shown on the Data Page and any guarantees stated in the Crediting hate Strategy endorsements. Guarantecd vahees may increase or decrease based on strategy allocations during the life of this Certificate, Any Withdrawal in excess of the Surrender Charge-Free Withdrawal amount will be assessed a Surrender Charge as follows: WNIC-GCOA-1205-0 4 r TABU OF SURRENDER CHARGIE PERCENTAGES Based an the age of the current older Owner on the date of receipt of each Premium Payment Premium Year Prior to Age B I Age 81 and older 1 12.110% 10.00% 2 12.00°Y. 9M A 3 MOM 8.00'/a 4 11.00% IMA 5 10.00% 6.00.6 6 9.00% 5.00% 7 8.000/0 4.000/6 8 7.000 3.00'/0 9 6.00% 2.00% 10 5.00% 1.00'/. I I and later 0.00% 0.00`/0 Surrender Charges may be waived subject to the provisions of this Certificate. ?n f.J .?4 .y N1 1;o ix .? p lv 5 WNIC-GCEIA-12054 DEFINITIONS Access is Surrender, any Transfer, any Withdrawal, payment of a Death Benefit, any Rider Deduction, or the application of the Certificate proceeds under a Settlement Option. Annuitant is an individual whose age and gender are used to deters ine the amount of Settlcrocia Option payments. The Owner and Annuitant need not be the same person. Upon the death of an Annuitant while the Owner is living, any surviving joint Annuitant will become the Annuitant. If there is no surviving Annuitant, the Owner shall autornatically become the Annuitant if the Owner is an individual. If there is no surviving Annuitant and dwre are joint Owners. then the joint Owners become joint Annuitants. In the event that she Owner is an Entity and joint Annuitants have been named, the joint Annuitants must be spouses. Unless otherwise indicated, "Annuitant" s1W) refer to more than one person if applicable. Annuity Value equals the sum of all the Strategy Values. Senafuiary is the persaa(s) designated by the Owner to receive die Death Benefit if the Owner dies bc%re the Maturity Date and there is no joint Owner. Certificate is this annuity contract. Certificate Year is the 12-month pcnod measured from the Effective Date. and each succeeding 12-month period. Crediting Rate Strategies are the methods for determining the amount of interest credited to this Certificate. The Crediting Rate Strategies are established by Endorsement to this Certificate. 'a Deatb Benefit is the amount payable as a result of the death of an Owner before the Maturity Date. Effective Date is the date the first Premium Payment is received by the Company at its Administrative Office and the date this Certificate becomes effective. Entity is a non-natural person, such as a inst. Gross Withdrawals are Withdrawals plus any assessed Surrender Charges and Markel Value Adjustments. ?-? initial Premium is the total of Premium Payments received on or before the Issue Date. Ifportions of the Initial Premium are `r received at different times, each will be applied to the applicable Crediting Rate Strategy as of the date each is received at the Company's Administrative Office. lerevocable Beneficiary is a Beneficiary so designated by the Owner. Certain subsequent changes to this Certificate require the permission of any Irrevocable Beneficiary. Issue Age is the age on the Effective Date of the older Owner, or if the Owner is an Entity, the older Annuitant. A person's age is determiner) as of his or her last birthday. Issue Date is the date this Certificate is issued. Market Value Adjustment is an adjustment that may be applied in the cotMutation of Surrender Value and Withdrawal amounts during the Surrender Charge periods. Maturity Date is the date payments are required to begin under a Setdemcut Option as shown on the Data Page. Minimum Guaranteed Interest Rafe is the annualized intertst rate credited to the Minhiimre Guaranteed Surrender Value. The rate is shown on the Data Page. WNIC-GCFJA-12os-0 6 Minimum Guaranteed Surrender value equals 87.506k of Premium Paymentq received, minus Withdrawals and any hider Deductions as they occur, all accumulated at the Mizdmum Guaranteed Interest Rate for the life of this Certificate. The Minimum Guaranteed Interest Rate is shown on the Data Page. Nonquatified for purposes of this Certificate is defined as a Certificate funded with after-tax dollars. Owner is any person or kmity with an ownership interest in this Certificate. If then is more than one Owner. the Owners mist be spousal and txtrcise ownership rights jointly. Unless otherwise indicated, "Owner" as used in connection with the exercise of Certificate rights shall refer to more than one person if there are joint Owners. PnhWuin Payments are the amounts paid for this Certificate and received by the Company at its Administrative Office. Each Premium Payment will have its own Premium Year. Premium Year is the 12-month period measured from the date each Premhtm Payment is received, and each succeeding 12. moth period. Qualified means that this Certificate is issued in connection with a tax-qualified redrement arrangement such as an IRA, SEP IRA or pension or profit-sharing trust. Rider Deductions art the charges and deductions for any additional benefits or riders attached to this Certifcate .= Settlement Option is a method that may be elected for receiving payments of this Certificate's proceeds over a fixed period, .:rl in a fixed amount or over the lifetime(s) of the Annultatit or a designated person(s). A Senlernent Option may be elected by l.n the Owner or by the person to whom Death Bencrits an payable. 1u I FJ Strat Valise equaks Premium Payments and Tram€ers allocated to the applicable Crediting Rate Strategy; p]us any interest credited; minus any amounts deducted for Gross Withdrawals, Transfers and Rider Deductions. 1D Surrender is the removal of all available Certificate values at or before the Maturity Date. "Surrender" shall be interpreted to ey include other Withdrawals where appropriate. Surrender Charge is a charge that may be assessed for a Surrender or Withdrawal. It is used on the age of the current older Owner on the date the Premium Payment is received and the y=rs that have elapsed Since the receipt of each affected Premiurn Payment. The amount of the charge is based an the Table of Surrender Charge Percentages for each Premium Payment, as sbowii on the Data Page. •s :o ?.v Surrender Charge-Free Withdrawal is an amount that is not subject to Surrender t:hatges or Market Value Adjustments upon Access. Surrender Charge-Free Withdrawal Percentage is the percentage: used to detertttine the amount of the Surrender Charge- Free Withdrawal. The Surrender Charge-Free Withdrawal Percentage is shown on the Data Page. Surrender Value is the amount payable upon Surrender of this Cenifrcate. It is equal to the greater of-- (a) the Annuity Value, adjusted for any applicable Market Value Adjustments and Surrender Charges, or (b) the Minimum Guaranteed Surrender Value. Transfer is an amount reallocated from a Crediting Rate Strategy to another Crediting Rate Strategy. Withdrawal is an amount paid to the Owner under the Withdrawals provision. WNtC GCBIA P05-0 GENERAL PROVISIONS This Certificate This Certificate is the entire contract between the Owner and the Company. It consists of. a) the pages of this Certificate; b) the applicaton; and c) any endorsements6 riders, or amendments attached to it when it is issued or subsequently added to it. Effective Date This Certificate is effective as of the Effective Date shown an the Data Page. Certificate Years and anniversaries are deternuned from the Effective Date. lncontesttabifity This Certificate is incontestable From the Effective Date. Misstatements If the age or gander of an Owner or Annuitant has been misstated, benefits will be adjusted to the carrcct amount for the true age or gender. The Company will correct underpayments in a lump sum on, the next payment date. 'l he Company. will deduct overpayments from the current or succeeding payments. Age will be calculated as of the last birthday. Administrative Error .J This Cerriticate describes the annuiry bcmfits to be provided hereunder- No action by the Company, whethe{ by mistake or ,r, otherwise, will convey any greater or lesser benefit other than that which was applied for, and for which prernimns have been ;-1; paid. :a Owner ?-' The Owner possesses all rights described in Ibis Certificate, subject to the Death Benefit provision. If no Owner is named for this Certificate, the Annuitant will be the Owner. if at the tine of application no Owner is natned and them; are joint • Annuitants that are spouses, the joint Annuitants will he the joint Owners. If there are joint Amtaitants and they are not spouses, an Owner must be named. In tltc event there are joint Ovmers, all elections and other actions which may Otherwise be ''° taken by the Owner pursuant to the reigns of this Certificate require joint action of such Owners. If there are joint Owners, the election or other action of either Owner alone will be ineffective. Joint Owners must be spouses. Prior to the Maturity Date and prior to a death that causes payment of a Death Benefit, the Owner may have the right to, but is '-r not limited w ?u $-:4 a Name and/or change the Beneficiary(ies). • Make additional Premium Payments to this Certificate. • Make Withdrawals from and Transfers within this Certificate. • Select the mrrltod for distribution of the Death Bencfit under the Settlement Options provision. • Select and/or change a Settlement Option. • lame a payee to receive payments tinder it ScWetttcnt Option. • Surrender this Certificate and receive the Surrender Value. ¦ Select a Crediting Rate Strategy. When the Owner is ready to excycise any of these rights, the Company roust receive the Owner's instructions in a form and manner acceptable to the Company. These tigbcs may be subject to certain limitations. Contact the Company's Administrative Office for the necessm y forms to take any action. INNIC GCEIA-1205-0 Beneficiary The Beneficiary is the person or petsons to whom the Death Benefit may become payable if: • The Owner dies before the Maturity Date and there is no joint Owner; or The Owner dies after the Maturity Date and Settlement Option payments have begun cruder a Settlement Option that guarantees payments for a certain period of lime. If no Beneficiary is narned. any Death Benefit will be paid to the Owner's or Owners' estate, if applicable. The Owner may name or change it Beneficiary at any time. The change will be effective an the date the change request was signed, but will not apply to any action taken by the Company before receiving written notice of the change:. If the Owner names an Irrevocable Beneficiary, certain subsequent changes the Owner makes to this Certificate must also include the written consent of the Irrevocable Beneficiary, except as otherwise required by law. The Owner can select the Settlcni [ Option that any Beneficiary must take. If more than one primary Beneficiary is named, each named Beneficiary will share equally in any benefit or rights granted by this Certificate, unless the Owner gives the Company other instructions. If more than one.contirtgeiu Beneficiary is tamed, each named Beneficiary will share equally in any benefit or rights granted by this Certificate, unless the Owner gives the Company other instructions. Death Benefit The Death Benefit is the amount payable as the result of death of an Owner before the Maturity Date. The Death Benefit is determined as of the date of death. The Death Benefit is equal to the greater of. • Annuity Value; or Surrender Value. Proof of Death Before the Company pays any Death Benefit, the Company must receive proof of death acceptable to the Company. This may include one or more of the following: -4 • A certified copy of a death certiticare. A certified copy of a court decree stating the cause of death • A.ity other proof or documents the Company nay require. Death Before the Maturity Date upon the death of any Owner before the Maturity Date, the Company will pay'thc Leath Beneflr as specified in this suction. The Death Benefit will not be paid upon the death of as Atmititani, unless the Owner is an Fixity. The manner in which the Company will pay the Death Benefit depends on the relationship and/or status of the person(s) involved in this Certificate. 1p This Certificate will terraainsie upon a death that causes payment of the Death Benefit except for the applicable provisions of Ian this se?tioa. The Death Benefit will be payable to the first person from the applicable list below: if'theOwner is rheAnnakant and the Owner dies.- * The joint Owner, if any. • The Beneficiary. If the-Owner is nor the Anreariratart 4nd else Owner dies: ? The joint Owner, if any; Tht Beneficiary. Itt any event, the Death Benefit shall be paid in accordance with Section 77(s) of the Intenmi Revenue Code. W.NIC-GCEIA-1305.0 9 If the Owner is an Eadit% the death of an Annuitant is treated as the death of the Ovvner, as provided in Internal kt:vetnttc Code Section 72(x)(6). The Death Benefit will be payable to the first person from the applicable list below. • The)oint Annuitant. if any, • The Beneficiary. The Beneficiary can elect this Certificate to retrain in force with the Annuitant's surviving spouse as the new Annuitant if- • This Certificate is owned by a trust; and • The designated Beneficiary is either. (1) the Annuitant's surviving spouse; or (2) a trust holding this Certificate solely for . the benefit of such spouse. If fhc Deem Benefit is payab is to the Owner's surviving sporese (or to a trust for the sole benefit of the Owner's surviving spouse), the Company will continue this Certilkate with the Owner's spouse as the Annuitant (and the Owner, as applicable). unless the Owner's spouse selects a lump sum payment or a Stttlenient Option. If the Drank Benefit is payable to someone other than the Owner's surviving spouse, the Company will pay the Death Scnefit in a lurnp sum to, or for the benefit of, such Beneficiary(ies) within one year, unless such person selects a Settlement Option as provided in this Certificate. in ilea of a lump scent Death Benefit, the individual to whom the Death Benefit is payable may select a Settlement option within sixty (60) days after the Company has received proof of death. Such payments must begin within one year after the Owner's death, and a) must be in equal payments over five years; or b) a period of time not extending. beyond the ,:n Beneficiary's life or life expectancy. .W .,n if the person to wham the Death Benefit would orkerwise /tape been payable dies at the time of, or within six (6) days after. the death that initiated payment of the Death Benefit, the Company will pay any benefits as if such person had died before such decedent. If a person to whom the Death Benefit is payable dies thereafter, but before the entire Veath Benefit is paid. the Company will pay the remaining Death Benefit in a lump sum to. a) the payee named by such person; or b) if no payee .) .y was named, to such person's estate. . a Death After the Maturity Date See the Sl TTLEMENT OPT ONS section. Maturity Date .. The Maturity Date is the Certificate anniversary following the 93* birthday of the person whose age determined the Issue "n Age. The Maturity Date is shown on the Aata Page and cannot be changed. The Maturity Date is the bate payments are ,.;0 required to begin under a Settlement Option, Authority to Change No part of this Certificate may be changed unless done in writing and signed by an authorized officer of the Company. The Company will not snake any change that reduces the amounts payable tinder this Certificate unless the change is required by law. The Company will give tht: Owner a copy of any changes made to this Certificate. Income Tax Qualification This Certificate is intended to qualify as an annuity contract for federal income tax ptirposes. All provisions will be interpreted to maintain such tax qualification despite any other provision to the contrary. The Company reserves the right to change this Certificate to reflect any clarifications that may be needed or are appropriate to maintain this qualification. The Company will give the Owner a copy of any changes trade to this Certificate. Laws This Certificate is governed by the-laws of the jurisdiction in which it is delivered. All values and benefits available under this Certificate are at least equal to those required by that jurisdiction. WNSC GCEiA 1205-0 10 Nonparticipating This Certificate pays no dividends and the Ownct has no voting rights. It does not strafe in the Company's profits er surplus. Periodic Reports The Cornpany will send the owner a statement regarding this Certificates Annuity Value, Surrender Value, and activity at least once per year until: a) the Owner starts Settkmant Option payments; or b) this Certificate is surrendered or otherwise terminated, PRENU MS AND CREDITING RATE STRATEGIES Premiums The Initial Premium received by the Coitpany. as shown on the Data rage, establishes this Certificate. If the current older Owner (older Annuitant if the Owner is an Entity) is less than age 86. the Owner may make additional Prenmiarn Payments to this Certificate. The Owner may allocate Premium Payments among the various Crediting Rate Strategies then available. The Company reserves the right to limit additional Prerniurn Payments to this Certificate. Premium Payments are allocated by the Owner to the Crediting Rate Strategies as desan'bed in the endorsements. The Company may return any portion of a Premium Payment that would cause it to exceed any federal or state litritatiam oq Prettuum Payn=ts during any taxable year. At any time, the Company may cease to accept Premium Paynx4 ts, Transfers or renewals to a specific Crediting Rate Strategy. In that event, any new Premium Payments will be allocated subject to the terms and conditions of the strategies available at that time. Whether or not the Owner makes any additional Premium Payments, this Certificate will continue to be in effect until all values are distributed. Crediting Rate Strategies The Crediting Rate Strategies fbr this Certificate am added to and made a part of this Certificate by endorsernem fiacb ?-+ available Crediting Rate Strategy is csoblished by a separate endorsement. After the Company tuns established a Crediting Rate Strategy. Premium Paytrrents may be allocated and values transferred to the Crediting Rate Strategy in accordance with the provisions of this Certificate and the applicable endorsement. The endorsement shall establish the tttethod by which interest is credited to the Strategy Value associated with the applicable Crediting Rate Strategy. Certain Crediting Rate Strategies may have lirnitations and restrictions. See the endorsements for further infomoation. ANNUITY AND SURRENDER VALUES Strategy Value This Certificate's Strategy value equals- a Premium Payments and Transfers allocated to the applicable Crediting Rate Strategy; plus • Any interest credited; minus Any amounts deducted for Gross Withdrawals, Transfers and Rider Deductions. Annuity Value This Ceri feaWs Amruity Value equals the sum of aU the Strategy Values- Minimum Guaranteed Surrender Value This Certificate's Minimum Guaranteed Surrender Value equals 87.50% of Premium Payments received, minus Withdrawals and any Rider Deductions as they occur, all accumulated at the Mhdmm Guaranteed Interest Rate for the life of this Certificate. 'lyre Minimum Guarawcod lntt:xgg RAw is shown an the Data Page. WWf' GCP'A-P20S-0 11 Surrender Value The Sttnender Value is the amount payable upon Surrender of this Certificate. It is equal to the greater of (a) the Annuity Value, adjusted for any applicable Market Value Adjustments and Surrender Charges, or (b) the Minimum Guaranteed Surrender Value. Sf the Surrender Value is reduced to less than $1,000, the Company reserves the right to pay the Surrender Value to the Owner in a lump sum. .r w 14-? .y ?J •x+ 1-- .1, Withdrawals The Owner nay withdraw pact of the Annuity Value at any time: a) following 34 days after this Certificate's Effective Date; and b) at or before the Maturity Date. A Withdrawal may not exceed the Surrender Value. The Company will use the Annuity value as of the date of Access in determining whether a Surrender Chargc or Market Value Adjustment will apply. The minimum Withdrawal amount is $500. Unless the Owner makes a different election, Withdrawals will be allocated to each Crediting Raic Strategy based on the percentage of the Annuity Value it represents. Within each affected Crediting Rate Strategy, Withdrawal amounts are processed against the values associated with each underlying Premium Payment, begirim with the earliest. The Company reserves the right to defer payment of any Withdrawal for up to six months, if approved by the Department of Insurance. Surrender The Owner may surrender this Certificate at any time for its Surrender Value. A Withdrawal that equals the Surrender Value Will be treated as a Surrender of this Certificate and will terminate all of the Company's obligations under this Certificate. The Company reserves the right to defer payment of any Surrender for up to six (0) months, if approved by the DeparCmcm of Insurance. Market Value Adjustment Upon Surrender or Withdrawal. a Market Value Adjustment may be applied to the Strategy Value of a Crediting Ratc Stratejy during the Surrender Charge period if more than the Surrender Charge-Free Withdrawal Percentage or the Annuity Value is Accessed during any Certificate Year. The Surrender Charge-Free Withdrawal Percentage is shown on the Data Page. Any Market Value Adjustment will be calculated by multiplying the amount Accessed, in excess of the Surrender Charge- Free Withdrawal, by the forimla described below: j(I + A)/ I + D f 0.005)1"-1, where A = 10-year Constant Maturity Treasury Rate (expressed as a decimal) reported by the Federal Reserve in effect on the date the Premium Payment is received. B - N-year Constant Maturity Treasury 'Rate (expressed as a decimal) repotted by the federal Reserve in c#Teet on the date the Market Value Adjustment occurs. N -Remaining number of days in the Surrender Charge duration for each affected Premium Payment divided by 365. If the Constant Maturity Treasury Rate is not available on a specified date, the Company will use the first preceding day that the Constant Maturity Treasury Rate is availsble. If the Contract Maturity Tmasury Rate is not published for a specific term, A or 13 will be obtained by linearly intetpolating between the two closest published rates. Surrender Charges Except in tlic cast of Stti'tcadef Charge-Free Withdrawals, a-Surrender Charge may be assessed on amounts withdrawn from this Certificate. The Surrender Charge will be determined by applying the Surrender Charge Percentage against each portion of the amount withdrawn in excess of the Surrender Charge-Free amount, adjusted for any applicable Market Value Adjustments. WN1C-GCF1A-120s-0 12 The Surrender Charge Percentage is based on the age of the current older Owner on the date the Premium Payment is received and the years that have elapsed since the receipt of each affected Premium Payment. The amount of the charge is based on the Table of Surrender Charge Perctanages for each Premium Payment. as shown on the Data Page. ?n ?,t ,-I Surrender Charge-Free Withdrawal A Surrender Charge-Free Withdrawal is not subject to a Surrender Charge or Market Value Adjustment. Minimian Required Distributions arc considered Surrender Charge-Free Withdrawals. Surrender Charge-Free Withdrawals are available each Certificate Year. A Surrender Charge-Free Withdrawal is an amount that does not exceed the greater of: a) The Surrender Charge-Free Withdawal Percentage of the Annuity Value, reduced by any Surrender Charge-Free Withdrawals taken during the Certificate Year. b) Minimum Required Distribution for Otis Certificate, reduced by any Surrender Charge-free Withdrawals taken during the Certificate Year. The Company will use the Annuity Value as of the date of Access in determining whether a Surrender Charge will apply. Conf uetnent Waiver This provision does not apply if an Owner or Annuitant (if the Owner is an entity) is confined in a Hospital, Hospice Facility or Nursing Home on the Certificate Effective pate- Subject to the terms of this provision, the Owner may request a Surrender or Withdrawal without incurring it Surrender Charge, if the Owner (both individuals in the case of joint Owners) is confined in a Hospital, Hospice Facility, or Nursing Home. If the Owner is an Entity, this Confinement Waiver will be based on the confinement of the Annuitant (both Annuitants in the ease of joint Annuitants). The amount available without Surrender Charge is listed below and is based on the age of the younger Owner or if the Owner is an Entity, the younger Annuitant at the rim this Certificate was issued. Ile Confinement Waiver will not apply if there is a change in the Owner (or an Annuitant if the Owner is an Entity) after the Certificate is issued. Age 70 or below 100% of the greater of the Annuity Value or the Minimum Guaranteed Surrender Value at the time the request is complete. Age 71-80 50d/o of the greater of the Annuity Value or the Minimum Guaranteed Surrender. Value at the time the request is complete. Age 81 and above 25% of the greater of the Annuity Value or the Minimum Guaranteed Surrender Value at the time the request is complete. The amount available without Surrender Charges and Market Value Adjusurients under this provision will be reduced by any Surrender Charge-Frye Withdrawal amounts taken during the Certificate Year and reduced by any Surrender Charge-Free Withdrawal amounts previously taken under this provision. Any amounts taken under this provision will reduce the amounts available under the Surrender Charge-Free Withdrawals provision. No additional Premium Payments will be accepted after the Owner has received a Withdrawal in accordance with this Confm=cw waiver provision, Amounts received under the Confinement Waiver will only be payable to the Owner. Payment will be made in either a lump sum or no more frequently than atonally. Tbis provision may be exercised once during the lifetime of this Certificate. The Company will not assess a Surrender Charge on that portion of the Annuity Value accessed through a Ulithdrawel if the following conditions are saiisfivd: 1. A written request must be received by the Company's Administrative Office, signed by the Owner, requesting a Withdrawal pursuant to the terms of this Coadinerr t Waiver provision. 2. The Owner is not confined in a Hospital, Hospice Facility or Nursing Home on the Certificate Effective Darr. 3. The Owner must be confined to a Hospital, Hospice Facility or Nursing Hone for at least sixty (60) consecutive days. W MC-GCEIA-1205-0 13 4. The Owner must request the Withdrawal no later than ninety (90) days following the date that confinetttcnt has ceased. The Owner must be living at ft time ail required documentation is received by the Corrtltany's Administrative Office. 5. Written documentation from a Physician must be provided to the Company that such confinement was recommended because of an injury or Sickness (as defined below). 6. Written proof of confinement from the fatality, indicating the type of facility and specific services provided, must be provided to the Company. Hospice Facility means an institution that provides a formal program of care for terminally iff patients whose life expectancy is less than six (6) months, provided on an inpatient basis and directed by a physician. It must be licensed, certified or registered in accordance with state law. Hospital means an institution which: (i) is licensed as a Hospital and operated pursuant to law; and (ii) is primarily engaged in providing w operating (either on its prianises or in facilities available to the Hospital on a prearranged contractnaJ basis and tinder the supervision of a staff of one or more duly licensed Physicians) diagnostic and nujor surgery facilities for the medical care and treatment of injured and sick persons on an inpatient basis for which a charge is made; and (iii) provides 24- hour nursing service by or under the supervision of a graduate regisirrod nurse (RNJ on duty or on call- a-+ ,w ?-a .,t Hospital does not inclade any institution which; is principally a rest home, Nursing Home, convalescent home, home-for the aged; or is principally an institution for the care and treatment of alcohol or chemical dependency. Nursing Horne means a facility that is licensed and operated primarily to provide nursing care for a charge (including room,: and board), according to the laws of the jurisdiction in which it is located. A Nursing Home may be a freestanding facility or it may be a distinct part of a facility, including a ward or a wing of a Hasp ital or other facility. Nursing Home does not mean: (1) a Hospital or clinic; (2) a rest home (a home for the aged or a recir+cmcnt home) which does not, as its primary function, provide custodial care; (3) the Owner's home; or (4) a facility for the treatment of alcoholism, drug addiction, or mental illness. Physician means a practitioner of the healing arts, who is duly licensed by the state to treat the Injury or Sickness causing the loss and who is not a member of the Owner's family or an employee of the Nursing Home or Hospice Facility where the Owner is confined. Injury means an accidental bodily injury that results in a qualifying confinement. Sickness means an illness, disease, or physical impairmenk which is diagnosed by a Physician. SETTLEMENT OPTIONS Benefit Amount On the Maturity Daze, the greater of: a) the Annuity Value. or b) the Minimum Guaranteed Surrender Value; adjusted for any applicable premium-related taxes, fees, or assessments imposed by any Federal, State or Municipal taxing authority, may be applied to one of the Settlement Options described below. Upon the Owner's death, the amount applied to a Settlement Option is the Death Benefit adjusted for any applicable prerniurn taxes. When Payments Begin Settlement Option payments will begin on the Mativiry Date, provided the Annuitant is alive on the Maturity Date. The owner chooses whether the Company will provide payments monthly, quarterly, sertii-arntually, Or annually, subject to the minimum settlement option payment. Once Settlement Option payments begin, the Settlement Option elected is irrevocable. WNIC-GCEIA-1205-0 14 The Marnrity Date is shown on the Data Page. To change the Settlement Option, the Owner trust notify the Company at least thirty (30) days before the Maturity Date. if the Owner does not choose a Settletneat Option, payments will begin under- a Life Annuity with 10 years certain. Upon commencement of the Settlement Option payments, this Certificate will terminate except for the applicable provisions of the Settlement Options section. Supplementary Contract upon request for a Settlement Option, the company will prepare a supplementary contract stating the tertrts under which the Company Vitt make payments. The suppkmentary contract will state to whom the Company will pay any remaining proceeds if the payee dies. The Company will require this Certificate in exchange for the supplementary contract. 1f any pay=nt is contingent on any Annuitant. Owner, or any Beneficiary being alive, the Company may require satisfhctory proof of survival. If the payee dies before payments under the supplementary contract are complete, the Company will pay any remaining balance at least as rapidly as under the method of payment in effect an the payee's date of death. Minimum Settlement Option payments if the amount of each paymear is less than S50. the Company may change the frequency so that this minimum amount may be met. If the amount to be applied to a Settlement Option will not provide payments in an amount at least as much as this ,Z) minimum, the Company may: a} pay the amount to be applied to a Settlement Option in a Iump sum; and b) terminate this 7) Cettificate. K; Settlement Options The Owner may choose from the following Settlement Options. Please contact the Company's Adminisaative Office for -.r • current availability. Option L Interest The Company provides payments of interest at not less than 1.00% per year. Interest will be paid or will e-J accrue each year for any period of time equal to or exceeding five years. The amount remaining at the end of the period will be piid in a lump sum or in another manner approved by the Company. The Company reserves the right to limit the maximum length of the period. Option 2 Fixed Payments-Tlte Company provides payments for a fixed period from five years to thirty years or in a stated ?--? amount to be paid out over not less than five years until the proceeds and interest are fully paid. The Company reserves the right to change the maximum length of the period. :.a Option 3. ,fife Annuit -The Company provides payments over the Annuitant's life. Payments end with the last paymeal made before the Ataruitant's death. If the Annuitant dies after receipt of the first payment no further payments will be due under this option. Option d. We Annuity with a Period Crrtein--ne Company provides payments for as long as the Annuitant lives, if the Annuitant dies before the selected period certain is over. the Company will continue making payments until the end of the period certain. The Owner may choose a period certain of 5, 10, 15 or 20 years. Option S. Joinr and Survivor dnnaity-The Company provides payments for as long as either the Annuitant or the joint Annustartt lives. When the first Annuitant dies, pay bents will continue in an amount equal to 100% 66 213% or 50°x6 of the original payments, as selected. Payments end with the last payment before the second Annuitant`s death. If both Joint Annuitants die after receipt of the rust payment, no further payments will be due under this option. Option 6. Joint and Survivor Annuity w0 a Pedad Certain ---The Cornpany provides payments for as long as either the Annuitant or the joint Annuitant fives. When the (irit "Atnuuitant dies. payments will continue is is 1`it"riaihtit equal` b 1`00%. 66 21 A or 50% of the original payments, as selected. If the second Annuitant dies before the selected period certain is over, the Company will continue making payments until the end of the period certain. The Ovvow may choose a period certain of 5, 10, 15 or 20 years. WN)C GCEIA 1705 0 Is Age Adjustments For settlement apttons 3, 4, 5, and b and Table B on the following pages, the payee's settlement age is the payee's age, nearest birthday, on the dine of the first payment, minus the age adjussment. The age adjustments ate shown on the table below and are based on the date of the first payment. For each decade after 2050, add an additional year of attained age set back. Amuiti- ation xW 2005 - 2010 2011 - 2020 2021 - 2030 2031 - 2040 2041 - 2050 Attained Age Set Ba 1 2 3 4 5 Other Forms of Payment payments may be provided under other Settlement Options not described in this section. Contact the Company's Administrative Office for more information What the Company May Need in order to start receiving Settlement Option payments, the Company may require proof of the Annuitant's or Annuitants', if applicable, age and sex. The Company reserves the right to retloire proof that the Amtuitam is living on the date of any payment. M V .?o Ir- +n WNtC GCMA 1200-0 16 Guaranteed Annuity Rates and Tables OPTION 2 - TABLE A FIXED PERIOD MINIMUM INCOME TABLE" Monthly Payments for each S1,000 applted Number Monthly Number Monthly Number Monthly of Years Installments of years Installments of Years Instatltrtents 1 63.7t 11 7.99 21 4.40 2 42.07 12 7.36 22 4.22 3 28. t 8 13 6.83 23 4.05 4 21.24 14 6.37 24 3.90 5 17.08 • IS 5.96 25 3.76 6 1430 16 3.63 26 3.64 7 12.32 17 3.33 27 3.52 6 10.83 18 S,05 28 3.41 9 9.69 )9 4.81 29 3.31 10 8.75 20 4.59 30 3.21 'Values ate based on an annual Interest rate of I-WA. OPTIONS 3 and 4 - TABLE B MWIMUM GUARANTEED PAYOUT A..NWTY TABLE«" Monthly Paymeau for each $1,000 applied senlemtnt Life Only Ineame Life S Years Certain 1-ife 10 Years Certain Life 15 Years Certain Life 20 Years Certain Age Male Female Male Female Male Female Male Female Male: Female 25 1.93 t.84 1.93 1.84 1.93 1.84 1.93 1.84 1.93 1.84 26 1.96 1.86 1.96 1.86 1.96 1.66 1.95 1.86 1.95 1.B6 .: 27 1.98 1.88 1.98 1.88 1.98 1.88 1.98 1.88 1.98 1.88 p 28 2.01 1.91 2.01 1.91 2.41 1.93 2.01 1.91 100 1.90 29 2.04 1.93 2.04 t.93 2.04 1.93 2.03 1.93 2.03 1.93 30 2.07 1.96 107 1.96 2.07 1.96 2.06 1.96 2.06 1.95 0 31 2.10 1.98 2.10 1.98 2.10 1.98 2.09 1.98 2.09 1.98 32 2.13 2.01 2.13 2.01 2.13 2.09 2.12 3.01 2.12 2.01 33 2.16 IN 2.16 2.04 216 2.04 2.16 2.04 2.15 2.03 '10 34 2.19 2.07 2.19 2.07 L19 207 2.19 2.07 2.18 2.06 •• 35 2.23 2.10 2.23 2.10 2.23 2.10 2.22 2.10 2.22 2.09 36 2.27 113 2.27 2.13 2.Z6 2.13 2.26 2.13 2.25 2.12 .x 37 2.30 2,16 2.30 2.16 2.30 2.16 2.30 2.16 2.29 2.15 38 2.34 2.20 2.34 2.20 2.34 2.20 2.33 2.19 2.32 2.19 39 2.39 123 2.39 2.23 2.38 2.23 2.38 2.23 2.36 2.22 40 2.43 2.27 2.43 2.27 2.42 2.27 2.42 126 2.40 2.26 41 2.47 2.31 2.47 2.31 2.47 1.31 2.46 2.30 2.45 2.30 42 2.52 2.35 2.52 2.35 2.52 2.35 2.51 2.34 2.49 2.33 .A) 43 2.51 2.39 2.57 2.39 2.56 2.39 2.55 2.38 2.53 2.37 .,) 44 762 2.44 2.62 2.44 2.62 2.43 2.60 143 2.58 2.42 49 2.68 2.48 2.68 148 2.67 2AS 2.65 2.47 2.63 246 46 2.73 2.53 2.73 2.53 2.72 2.53 2.71 152 2.68 130 47 2.79 2.58 2.79 2.58 2.78 2.57 2.76 2.57 2.73 2.55 48 2.85 2.63 2.85 2.63 2.84 2.63 2.82 2.62 2.78 2.60 49 2.92 2.69 2.91 2.69 2.90 2.68 2.88 2.67 2.84 2.65 SO 2.98 2.75 2.98 2.74 2.97 2.74 2.94 2.72 2.89 2.70 S1 3.06 2.61 3.05 180 3.03 2.80 3.00 2.78 295 275 52 3.13 2.67 3.12 2.87 3.10 2.86 3.07 2.84 3.01 2.51 53 3,21 2.94 3.20 2.93 3,1S 2.92 3.14 2.90 3.07 2.87 54 3.29 3.01 3.28 3.00 3.26 2.99 311 2.97 3.14 2.93 .S3 3.37 3.08 337 3.08 3.34 3.06 3.29 3.04 3.20 2.99 36 3,46 316 3.46 3.16 3.43 3.14 3.37 3.11 3.27 3.06 57 3.56 3.24 3.55 3.24 3.52 3.22 3.45 3.18 334 3.12 58 3.66 3.33 3.65 3.32 3.61 3.30 3.53 3.26 3.41 3.19 59 3.77 3.42 3.76 3.42 3.71 3.39 3.62 3.34 3.48 3.26 60 3.89 3.52 3.87 341 3.82 3.49. 3.71 3.43 335 3,34 WNIC-GCEIA-1205-0 17 r,lt r.? -r -`v .x. Settlement Age 61 fit 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 Be 81 82 83 84 85 86 87 BE 89 90 91 92 93 94 04 Life Only Income Male Female 4.01 3.62 4.) 4 3.73 4.28 3.85 4.43 3.98 4.58, 4.11 4.75 4.25 4.93 4.40 5.12 4.57 5.33 4.74 554 4.93 5.78 5.13 6.02 3.35 5.29 5.59 6.57 5.84 6.87 6.12 7.19 6.42 7.53 6.74 7.90 7.09 8.30 7.47 S,72 7.88 9.17 9.32 MS 8.80 10.17 932 M7.2 9.89 11.30 1030 11.93 11.15 12.59 11.85 13.30 12.60 1405 13.40 14.85 14.23 15.69 15.11 16.59 16.02 17.54 16.97 18.55 17.96 1964 19.00 Life 5 Years Certain male Female 3.99 3.61 4.12 3.72 4.25 3.84 4.40 3.96 4.55 4.09 4.71 4.23 4.88 4.38 5.07 4.54 5.26 4.71 5.46 4.89 5.68 5.08 5-91 5.29 6.15 5.52 6.40 5.76 6.67 6.01 6,95 6.39 7.2S 6.SS 7.56 6.89 7.88 7.22 8.22 7.57 5.58 7.95 9.94 8.34 9.32 8.75 9.71 9.17 10.10 9.61 10.50 10.06 10.91 10.51 11.31 10.96 11.72 1 t.41 12.12 11.84 12.52 12.27 12.91 12.67 13.30 13.07 13.67 13.45 14.05 13.82 Life 10 Years Certain Male Female 3.93 3.58 4,05 3.69 4.17 3.80 4.30 3.91 4.43 4.03 4,57 4.16 4.72 4.30 4.87 4.44 s.03 4.59 5.20 4.75 5.36 4.92 5.54 5.09 5.71 5.28 5.89 5.47 6.08 5.66 6.26 5.86 6.45 6.0? 6.63 6.28 6.81 6.49 6.99 6.70 7.16 6.90 7.33 7.10 7.48 7.29 7.63 7.46 7.77 7.63 7.90 7.78 8.02 7,92 8.13 8.05 9.23 8.16 8.32 826 8.40 8.35 8.47 8.42 8.53 8.49 5.38 8.55 8.63 8.60 Life ) 5 ycatS Ccrtxin IMa1c Female 3.81 3.52 3.91 3.61 4.01 3.71 4.11 3.51 4.22 3.92 4,32 4.02 4.43 4.14 434 4._5 4.65 4.37 4.76 4.49 4.66 4.61 4,97 4.73 5.07 4.64 5.16 4.96 5.26 5.07 5.34 5.18 5.43 5.29 5.50 5.38 5.57 5.47 5.63 5.55 5.69 5 62 S.74 5.68 5.78 5.74 5.82 5.75 5.85 5.8; 5.88 5 86 5.90 5.89 5.92 5.91 5.94 5.93 5.95 5.94 5.96 5.95 5.97 5.96 5.97 5.97 5.97 5.97 5.98 5.98 Life 20 Ycara Certain Male Female 3.62 3.41 3.69 3.49 3.76 3.57 3.83 3.64 3 X10 3.72 3.97 3,80 4.04 3.88 4.10 3.95 4.16 4.02 4.21 4.09 4.26 4.16 4.31 4.22 4.35 4.26 4.39 4.33 4.43 4.37 4.46 4.41 4.4S 4.45 4.51 4AS 4.52 4.50 4.54 432 4,55 4.54 4.56 4.55 4.57 4,56 4.58 4.57 4.58 4.58 4.59 4.58 4.59 4.59 4.59 4.59 4.59 4.59 4.59 4.59 4.59 4.59 4.59 4.59 4.59 4.59 4.59 4.59 4.59 4.59 ''' '• Minimum guaranteed payout rates are calculated based on Annuity 2000 Mortality Tables '11ie table is based on a minimum guaranteed I.n interest rme of 1.00% per year, Wn11C GCE1A 1205-0 IS WASHINGTON NATIONAL INSURANCE COMPANY Home Office: Chicago, Illinois Administrative Office: Past Office Box 7873, San Francisco, California 94120-7973 APPLICATION CLARIFICATION 1:p IJ 0 t.?J V n.+ 1+;? 'A I.n CERTIFICA'T'E ?NUMBER: NAME OF OWNER: QUALIFIED: ANNUITY TYPE: IRA Secretary VAR0002347 CLAM W. HEMMER PREMIUM TYPE: ROLLOVER 1'TCSidtSnl 1 wK1C-GEAR Apptimdevi, is made to Waslt scan Natlang Insnrent.e Campa:ty ("the COMTIMy") Home Qfce: Chicago, Minois Adta Wsbatlves or= post GMce Ban 7973; San Finadsco, CA 94M7873 ANNUM "PLICATION PIXAM IPMT AND QSR DA= ><1WK ONLY Primary Annuitaat No!!( fit w desirod an joint Annuitant (pot applieabte to qualirad ooairach) Name (print w dc*td on contract) Fast Middle Lest First Middle LOU AAt= Add= C• Stede Zrp City State Tip rtY Yefapbone l=.1? w T1&p oue .a, fm ?.n •w 1;o i' Gender 'A Made [ ] Females !'fir So0w Seeaasty Ibomber Date of Birth 5 MO Day r maribd Status Owner (ff 09mar is a trust„ Jndude aaaac and data) Namt Gender I I Male I I Female, Social SwAnity Number Date orBisth Birth gwe Mo Day Yr Marital stabs [ j joint Owwr (=W be Spam of owner) (not appfthle to gWIfied COMbW s) Nome First Middle Lust Fiat Midrtit Last Addre n Addeess Suva St<efd city state zip city Stde Zip Tekmbone T*upb= t------ 3 Gender I] Male 111Fewde SmolSeca t}r Number of 71 ix ID Nmnbe r Date of 13hib,. _ Mwimi Status MO Dw Yr Rela$eanslsip to Proposed Prig wy AmaUWO _ - Owde r I I Malt I I pewde social t3w=ty? Number or In ID Number bate of Birth Maeatal Statna Ma Day Yir Rtlatiooedt9p to Proposed Ptbwy Aza ukwt SWUON 3-•TBF ORNMCURT (if Bawfidwy is a =4 Wu& name and tilde.) If emly one beuefickry is electuf ad no aDncatim h ind9cetal, the aRocadon will L-fauit to 1oq%. If multiple bme&ia ies are ReYY1W1ila4 to Owner % RelatiesnsDt t0 4/YIY?i 7r WIJIGAPRlZD3 e ProductNaaAe +••t-detc,re. OpdojW BegeW or Rldws I } Benetielary Rider Me (Not avallabie wkh qualified eonttscts) (}Other HOME OFFICE CHANORS I(We) umdcrstaud that the Cataop my WM invent its gesrerai ace ML aaosets at its stale disartion Find no ono will have the right to direct the Company r.Anecrob the iaviceONAM owaad by the CaMPM7. The Prodnr" has so antharby to make, modify. after or duo any rontrsax. Acceptance of any contrao issued on this appliaWon will nd* d>aelges noted fry the Company in the space titled 'Ziwe ?-• Office C hangaP and a copy of the changed application gbmbe d to the counact will be suflyciamt notice of these dratoges. I(We) betrby auftdee uad direct the Company to accept and act an any and all tek low traosfier, withdmwad, ivaa of service hwanctions firm any person who can Furnish proper Ott, incluftg do SocW So=* Nrmtber or Tax ID Nmber ad pnsow se=* code of to ,M Owner. I{We) agree to b=p the pcraoml MOW* code coafidaotW and bear all risks associated wild wy(atar) diselos= to any turd ,. party. I(We) agree to hold bmweless and kxkmas* the Cwapeny and its affiliates and their dirwims, oftktts, employees and agate for my a"s dosses, fiabOftics, costs or entpmes wising Am acting an such Jostr7aetlons when believed to be genabrec. l(We) tnndeastaad that guy(our) tclepbece, colds to the Company (nay be recorded for our mvaW protactiotu Find cotwag to such rocotdlog. All statamems and answers an this sppikutiatl an futi, complete and true. If a trust is named as a Beneficiary,1(wwe) declare that The trust Is vvW and opcratiaaaal as of the date this application is 54freal. L(We) cot. (1) tom' Social Socurby or Tare ID Number(s) shown an this appiwootr is(are) coma".( and (Z) l(we) am(art) responsible for payamat of Federal and/or State Income Tax au lye taxably n portion of withilowsk df any, tad that I(we) may be subject tD am penalties under eSdtlsat d tax payment rules if my(our) payments of estinos tai and tax whbholdio& ifany, aratai adequate. "4 Any prior who kwwhtgfy and wad intent to defiand any msu ww a w4way ar odter person focs gm epp}kation for bmw non or a wmi nt of claim containing any matedaw thlse info 0n or Conceals for the propose ofmiaca tug. Edon coneeming Fiery fw auaate rw thereto commits a fined act, 'eb is a asane and subje t5 soma pesos to ciituival and ei+:71 Of Owns Sigaetttre of Joint Owner (if Qwaaer b not a natural person, print unman (e g., Trust Name and Trust Date) BY - --- Signature (C.16 Trwice Swzt+m, Ttustec) Title of AuOA*y dfOwnar I#' Owner is oat at naramnl neurone, aigt?try of d?riraeary Anoriitaat Sigawt?ua of 3oint Antaciitant ' aiSa:ar's - - ? titdt o-2'pity ?ovriedge, ?is-appiicc?oaa [ l ?dM zpaeor hat e4gc Kdora-not replace or lifie' or uY IaAtaat ?taease Prodeau=Number VNIC-APP-1205 iniilal Pt ett:fa:an: - - [ J NougnBMW [ I Qwlifled (Complete bete types) AiMWWMM Imp 75cye Catsb with Application Amaunt S J A 13 Cotntributioc SBP IRA Tax Year Tsi6aatod?ransfer Atnataut S _? (] Itotb-IRA [ } Dbed Trader [ } Other _ [ 3 Rog0ver-- --- - - - WASHINGTON NATIONAL INSURANCE COMPANY Administrative Office: Post Office Box 7873, San Francisco, California 94120.7873 Telephone (877) 549-7663 (Toll Free) (hereinafter called the Company) INDIVIDUAL RETIREMENT ANNUITY ENDORSEMENT The Owner of this Contract/Certificate (hereinafter referred to as "Contract') having so requested, 11 is hereby sgreed that as of the Contract Issue Date, the Contract shall be tnodifed ire the following particulars to qualify as an individual Retirement Annuity under Section 408(b) of the Internal Revenue Code of 1986, as amended (hereinafter called the "Code"). in the case of a conflict with any provision in the Contract, the terms of this Endorsement will control. 1. Ownership: The Owner and the Annuitant shah be the same individual and there shall be no Joint Owner. The Owner shal l hereinafter be referred to as the Annuitant. 2. ExcluWva Benefit: This Contract is established for the exclusive benefit of the Annuitant and the Beneficiaries of the Annuitant. 3. Distributions During Annuitant's We: (a) Notwithstanding any provision of this MA to the contrary, the distribution of the Annuitant's interest . in the IRA will be made in accordance with the requiretrtents of Code §408(b)(3) and the regulations: T, thueunder, the provisions of which are herein incorporated by reference. If distributions are not made in the form of an annuity on an irrevocable basis (except for acceleration), then distribution of the interest in the IRA (as determined under section 4(c)) must satisfy the requirements of Code §408(a)(6) and the regulations thereunder, rather than paragraphs (b), (e) and (d) below and section 4. (b) The entire interest of the Annuitant for whose benefit the Contract is maintained will commence to be ' distributed no later than the first day of April following the calendar year in which such Annuitant attains age 70% (the 'required beginning date') over (a) the life of such Annuitant or tives of such '?- Annuitant and his other designated beneficiary or (b) a period certain not extending beyond the life expectancy of such Annuitant or the joint and last survivor expectancy of such Annuitant and his or her designatrd beneficiary. Distributions must be made in periodic payments at intervals of no longer than 1 year and must be either nonincreasing or they may increase only as provided in Q&As - t and - 4 of §1.401(x)(9) - 6T of the Temporary Income Tax Regulations. In addition, any distributions- must ,-a satisfy the incidental benefit requirements specified in Q&A - 2 of §1,401(ax9) - 6T. .u (c) The distributiou periods described in paragraph (b) above cannot exceed the periods specified in •j0 § 1.401(ax9) •-'67 of the Temporary Income Tax Regulations. (d) nc first required distribution can be trade as late as April I of the year following the year the Annuitant attains age 70% and must be the amount that is required for one payment interval. The second required distribution need not be made until the end of the next payment interval. 4. Distribution Upon Death of Annuitant: (a) Death On or After Required Distributions Commence. If the Annuitant dies on or after required distributions commence, the remaining portion of his or her interest will continue to be distributed under the Contract option chosen prior to death. (b) Death Before Required Distributions Commence. If the Annuitant dies before required distributions comrnetrce, his or her entire interest will be distributed at least as rapidly as follows: IRA-2002 1 06102 (1) If the designated beneficiary is someone other than the Annuitant's surviving spouse, the entire interest will be distributed. starting by the end of the calendar year following the calendar year of the Annuitant's death, over the remaining life expectancy of the designated beneficiary, with such life expectancy determined using the age of the beneficiary as of his or her birthday in the year following the year of the Annuitant's death, or, if elected, in accordance with paragraph (b)(3) below- (2) If the Anmitant's sole designated beneficiary is the Annuitant's surviving spouse, the entire interest will be distributed, starting by the end of the calendar year following the calendar year of the Annuitant's death for by the end of the calendar year in which the Annuitant would have attained age 70K if later), over such spouse's life, or, if elected. in accordance with paragraph (bx3) of 4(e) below, if the surviving spouse dies before required distributiort_s commence to him or her, the remaining interest will be distributed, starting by the end of the calendar year following the calendar year of the spouse's death, over the spouse's designated beneficiary's remaining life expectancy determined using such beneficiary's age as of his or her birthday in the year following the death of the spouse, or, it elect,4 will be distributed in accordance with paragraph (b)(3) Wow, if the surviving; spouse dies after required distributions commence to him or her, any m natining interest will continue to be distributed under the contract option chosen. (3) If there is no designated beneficiary, or if applicable by operation of paragraph (b)(l) or (bx2) above, the entire interest will be distributed by the end of the calendar year containing the fifth annrversaty of the Atutuitant's death (or of the spouse's death in the case of the surviving spouse's death before distributions are required to begin under paragraph (b)(2) above). (4) We expectancy is determined using time Single Life Table in Q&A - t of §1.401(a)(9) - 9 of the JQ Income Tax Regulations. If distributions are being made to a surviving spouse as the sole designated beneficiary, such spouse's remaining life expectancy for a year is the number in the Single Life Table corresponding to such spouse's age in the year. In all other cages, remaining life expectancy for a year is the number in the Single Life Table corresponding to the beneficiary's age in the year specified in paragraph (b)(1) or (2) and reduced by 1 for each subsequent year. ? Q (c) 'fine "interest" in the IRA includes the amount of any outstanding rollover. transfer and recharacterization under Q&As - 7 and - 8 of §1.408 - 8 of the Income flax Regulations and the actuarial value of any other benefits provided under the IRA, such as guaranteed death benefits. (d) For purposes of paragraphs (a) and (b) above, required distributions are considered to commence on the Annuitant's required beginning date or, if applicable, on the date distributions are required to begin 1,,i to the surviving spouse under paragraph (b)(2) above. However, if distributions start prior to the applicable date in the preceding sentence, on an irrevocable basis (except for acceleration) under an 1.0 annuity Contract meeting the requirements of §1.401(a)(9) - 6T of the Temporary Income Tax Regulations, then required distributions are considered to commence on the annuity start date. (c) if the sole designated beneficiary is the Annuitant's surviving spouse, the spouse may elect to treat the IRA as his or her own IRA. This election will be deemed to have been made if such surviving spouse mattes a contribution to the IRA or fails to take required distributions as a beneficiary. to this instance, the spouse shall become the Owner and Annuitant under the Contract and for purposes of tic Endorsement, 5. Non-transferable: 11te Contract may not be sold, assigned, discounted pledged as collateral for a loin or as security for the performance of any obligation or for any other purpose, or otherwise transferred (other than a transfer incident to a divorce or separation instrusnent in accordance with Section 408(d)(6) of the Code) to any person other than to the Company by the Annuitant 6. Non-forfeitable: 'glee entire interest of the Annuitant under this Contract shall be non-forfeitable. IRA-2002 2 06102 T. Purchase Payments: Purchase payments shall be flexible and not fixed. (a) Except in the case of a rollover contribution (as permitted by ¢§402(c). 402(e)(6), 403(x)(4), 403(bx8), 403(bX 10). 408(dx3) and 457(tK 16) of the Code) or a contribution made in accordance with the terms of a Simplified Employee Pension (SEP) as described in §408(k), no contributions will be accepted unless they are in cash, and the total of such contributions shall not exceed: $3,000 for any taxable year beginning in 2002 through 2004; $4,000 for any taxable year beginning in 2005 through 2007; and 3500 for oily taxable year begitming in 2005 and years thereafter. After 2008, the limit will be adjusted by the Secretary of the Treasury for cost-of-living increases under Code §219(bx5)(C). Such adjustrttents will be made in multiples of $500. (b) in the case of an Annuitant who is age 50 or older, the annual contribution )irnit is increased by. $500 for any taxable year beginning in 2002 throush 2005; and S 1,000 for any taxable year beginning in 2006 and years thereafter. (c) No contributions will be accepted tinder a SIMPLE IRA Plan established by any employer putsvant 14 §409(p). Also, no transfer or rollover of funds attributable to contributions matte by a particular employer under its SIMPLE IRA Plan shill be accepted from a SIMPLE IRA, that is, an IRA used in . conjunction with a SIMPLE IRA Plan, prior to the expiration of the 2-year period beginning on the date the Annuitant firfit participated in that employer's SIMPLE IRA plan. .x, ?T (d) If premium payments are interrupted, this Contract will be reinstated at any date prior to maturity upon payment of a premium to the Company, and the minimum premium Mount for reinstatement shall be $50; however. the Company may at its option either accept additional future payments or teradnate the Contract by payment in cash of the then present value of a paid up benefit if no premiums have been received for two full consecutive Contract years and the paid up annuity benefits at maturity would be less than $20 per month. 8. 'R'hea this Endorsement is attached to a participating Contraet: Any refund of prernuarns (otbet thin !X those attributable to excess contributions) will be applied, before the close of the cakndar year following the year of the refund, toward the payment of future premiums or the purchase of additional benefits. 9. Annual Reports: The Company will provide die Annuitant with annual calendar year reports concerning the status of the Contract and information concerning required minimum dittrbutions as is prescribed by ,r the Commissioner of Internal Revenue by the date mandated by the Code and the Commissioner of internal ? Revenue. r? 10. Amendments to Maintain Compliance with Internal Revenue Code: The Company reserves the right to amend this Endorsement ro comply with the Code. In the event that the citations pertaining to any of the Temporary Income Tax Regulations referred to in this Endorsement are changed due to actions taken by the Internal Revenue Service or the U.S. Treasury Department, this Endorsement will operate as though it ware amended and updated to reflect such changes, but only with respect to the citations changed. Signed for the Company by: k '--Q w )?L Secretary TRA-2002 3 06/02 WASHINGTON NATIONAL INSURANCE COMPANY }]olne office. Chicago, Illinois Administrative Office: Post Office Box 7973, San Francisco. California 94120-7873 - Telephone (977) 549-7663 ('Poll Free) GUARANTEED ONE-YEAR FIXED RAVE STRA'T'EGY ENDORSEMENT THE ENDORSEMENT This Endorsement establishes the Guaranteed Otte-Year Fixed Rate Strategy for the Contract to which it is attached. If the Endofsernew and Contract define the same lemt, the definition contained in this F.ndorsemmi will apply. The terms of the }rndorsemm apply once the Owner allocates Premium Payments or Transfers into this Crediting Rate Strategy. CONTRACT For purposes of this Endorsement, Contract refers to the individual annuity policy or to the annuity certificate issued under a group policy. lA°TIR&ST CREDITED This Crediting Rate Strategy credits an interest rate declared by the Company. The interest rate is credited daily and is guaranteed not to change for a one-year period with respect to Premium Payments. Transfers and renewals allocated and receivc8 in this Crediting Rate Strategy. A new declared interest rate may be effective upon processing of a new Premium Payment. Transfer or renewal. The interest rate for this Crediting Rate StrmitMf will not be less than 1,50%. TRANSFERS AND REN%WAI.S . The Owner may request a Transfer into this Crediting Rate Strategy from another Crediting Raic Strategy at anytime, subject to any limitations stated in that Crediting Rate Strategy Endorsement. r? -,n ??> The Owner may request a Transfer at any time to another available Crediting Rate Strategy, subject to any limitations stated in that Crediting Rate Strategy Fndorsen=t. !a if a request for Transfer to another Crediting Rau Strategy is not received, the values in this Crediting Rate Strategy will `t automatically renew into a new one-year period with a new declared interest crediting rate. ?.r This Endorsenierit takes effect and ends with the Contract to which it is attached. Nothing contained in this Endorsement will be held to change, waive or extend any provisions of the Contract except as stated. Secretary President WNIC-M-1205 WASHINGTON NATIONAL INSURANCE COMPANY Horne Office: Chicago, Illinois Adnvnistrntive Office: Post Office Box 7873, San Francisco, California 94120.7873 - Telephone (877) 549-7663 (Poll Free) S&P 500 INDEX ONE-YEAR POINT-TO-POINT WITH CAP STRATEGY ENDORSEMENT THE ENDORSI•;MENT This Endorsement establishes the S&P 500 Index Otte-Year Point-To'Po'et With Cap Strategy for the Contract to which it is attached. if the Endorsement and contract define the same term, the definition contained in this Endorsement will apply. The terms of the Endorsement apply once the Owner allocates Premium Payrocnts or Transfers into this Crediting Rate Strategy. Premium Payments, IYausfers and renewals will be applied on the Allocation Dates determined by the Company. CONTRACT For purposes of this Endorsement, Contract refers to the individual annuity policy or to the annuity certificate issued under a group policy. ALLOCATION DATE The Allocation Date is the first day of the Term Period. It is the date declared by the Company for the allocation of each Premium Payment, Transfer at renewat into this Crediting Rate Strategy. The Allocation Date occurs within 32 datys after a) the Company's Administrative Office receives the Premium Payment, orb) the date of Transfer or renewal. INTEREST CREDITED The Coir"ny will calculate any interest to be credited and it will be added to the Strategy Value only at the end of each ..? Term Period. The inierest to be credited will be equal to the Strategy Value at the end of the Term Period before any interest is credited multiplied by the Interest Crediting Rate. If the Owner Accesses a portion of the Strategy Value before the end of the Term Period, the portion Aceessed will not be credited interest. INTEREST CREDI'T'ING RATE The interest crediting rate for this Crediting Rate Strategy will be the lesser of A or B, but not less than zero, where: A equals: a Index Value on the last day of the Term Period, divided by the Index Value on the Allocation Date, • minus one. ' B equals: hr Cap. CAP Cap is as interest rate declared by the Corripany for each Term Period antler this Crediting Rate Strategy, used in the calculation of interest credited w this Crediting Rate Strategy. The Company may declare a new Cap on or before each Allocation Date, and it will remain unchanged during the Tenn Period. The Minimum Cap is shown on the Contract Data Page. INDEX The Index for this Crediting Rate Strategy is the S&P SOD Index. The S&P 500 Index does not reflect dividends paid on the stocks underlying the index. If: a) the publication of the S&P 500 Index is discontinued; or b) the calculation of the S&P 500 Index is changed substantially, then the Company will substitute another widely published Index. The Company will notify the Owner of the change... The Crediting Rate Strategy for the new Index will have a corresponding Cap. WNIC-SP 1 YRC-1205 INDEX VALUE The Index Value will be the closing value of the S&P 500 index on a specified date. If the index Value is not available for such date, the Index Value used for that date will be the Index Value on the first preceding trading day for which it is available. TERM l'SR14D The Term Period is e(10) ter 12 consecutive months, fallowing the A13ncatinn Date_ It is used to measure any percetstagt change hi the Index. TRANSFERS AND RENEWALS The Owner may request it Transfer into this Crediting Rate Strategy from another Crediting Rate Strategy at any time, subject to any limitations stated in that Crediting Rate Strategy Endorsement. Transfers are not allowed if the Term Period would expire after the Maturity Date. The Owner may request a Transfer to another Crediting Rate Strategy, subject to any }imitations stated in that Crediting Rate Strategy Endorsement. '17te Company's Administrative Office molt receive the Owner's request to Transfer from this Crediting Rate Strategy at )east 7 days prior to the end of the Term Period. The Transfer will be processed at the end of the last Term Period. Transfers are not allowed during the Term Period. If a Transfer to another Crediting Rate Strategy is not requested, the Company will establish a new Term Period. The new Tenn Period will begin run the Allocation Date and will have a new corresponding Cap. If the Teem Period is no longer available or the Tenn Period would extend beyond the Maturity Date, then the Strategy Value will he transferred to the Guaranteed One-Year Fixed Rate Strategy. TERMINATION OF ENDORSEMENT ,r The Company may cease io accept Premium Payments, Transfers or renewals into this Crediting Rate Strategy. The Cotnpany may terminate this Endorsetttent 2120Y time. Upon termination, the Owner cannot allocate any Pretnium Payments, ,a Transfers or renewals to this Crediting Rate Strategy. Unless notified by the Owner prior to the Endorsement's termination -d date, the Strategy Value of this Crediting Rate Strategy will be transferred to the Guaranteed One-Year Fixed Rate Strategy. This Endomentcnt takes effacs and ends with the Contract to which it is attached. Nothing contained in this Endorserent will J-. beheld to change, waive or extend any provisions of the Contract except as stated. .70 Secretary President WN)CA l YRC-1205 WASHING'T'ON NATIONAL INSURANCE COMPANY Horne Office: Chicago, Illinois Administrative Office: Post Office Box 7873, Sett Francisco, California 94120-7873 - Telephone (877) 549-7663 (Toll Free) S&P 500 INDEX ONE-YEAR POINT-TO-POINT WITH PARTICIPATION RATE STRA'T'EGY ENDORSEMENT THE El1DORSEMEN'T This Endorsement establishes the S&P 500 Index One-Year Point-To-Point With Participation Kate Strategy for the Contract to which it is attached. If the Endorsement and Contract define the same term, the definition contained in this Endorsement will apply. The terrm of the Endorsement apply once the Owner allocates Prernium Payments or Transfers into this Crediting kale Strategy. Premium Payments, Transfers and renewals will be applied on the Allocation Dates determined by the Company. CONTRACT For purposes of this Endorsement, Contract refers to the individual annuity policy nr to the annuity certificate issued under a group policy. ALLOCATION DATE The Allocation Date is the first day of the Term Period. It is the dater declared by the Company for the allocation of each Premium Payment, Transfer or renewal into this Crediting Rate Strategy. The Allocation Date occurs within 32 days after: a) the Cornpany's Administrative office receives the Premium Payment; or b) the date of Transfer or renewal. .a MEREST CREDITED '.' The Company will calculate arty interest to be credited and it will be added to the Strategy Value only at the end of each Term Period. The interest to be credited will be equal to the Strategy Value at the end of the Term Period before any interest .0 is credited multiplied by the Interest Crediting Rate. If the Owner Accesses a portion of the Strategy Value before the end of '-t the Term Period, the portion Accessed will not be credited interest. V INTEREST CREDITING RA'Z'E The interest crediting Tate for this Crediting Rate Strategy will be as follows, but not less than zero: • Index Value on the last day of the Term Period, • divided by the Index Value on the Allocation Date, • minus one, "' • multiplied by the Participation Rate. ca INDEX The Index for this Crediting Ratc Strategy is the S&P 500 Index. The SW' 500 Index does not reflect dividends paid on flu stocks underlying the Index. If: a) the publication of tote S&P 500 Index is discontinued; or b) the calculation of the S&P 500 Index is changed substantially, then the Company will substitute another widely published Index. The Congiany will notify the Owner of the Change. The Crediting Bate Strategy for the new Index will have a corresponding Participation Rau. INDEX VALUE The Index Value will be the closing value of the S&P 500 Index on a specified date. If the Index Value is not available for such date, the Index Value used for that date will be the Index Value on the first preceding trading day for which it is available. WNIC-SPI YRPR-1205 PART'ICIPATIUM RATE Participation hate is a rate declared by the Company for each Term Period under this Crediting Rate Strategy. The Participation Rate will be used in the calculation of the Crediting Rate for the Term Period. The Company may declare a new Participation Rate on or before each Allocation Date, and it will remain unchanged during the 'Term Period. The Minimum Participation Rate is shown on the Contract Data Page. TERM PERIOD The. Term Period is equal to 12 consecutive months, following the Allocation Date. !t is used to measure any percentage change in the Index. TRANSFERS AND RENEWALS 'Tire Owner may request n 'transfer into this Crediting Rate Strategy ft em another Crediting Rate Strategy at any time, subject to any limitations stated in that Crediting Rate Strategy Endorsement. Transfers ate not allowed if the Term Period would expire after the Maturity Date. The Owner may request a Transfer w another Crediting State Strategy, subject to any limitations stated in that Crediting Rate Strategy Endorsement. The Corrtgany's Administrative Ofliee trust receive the Owner's request to Transfer from this Crediting Rate Strategy at least ? days prior to the and of the Tenn Period. The Transfer will be processed at the end of the last Term Period. Transfers are not allowed during tht Term Period. if a Transfer to another Crediting Rate Strategy is not requested, the Company will establish a new Term Period. The new Terns Period will begin an the Allocation Date and will have it new corresponding Participation Rate. If the Terra Period is no longer available or the Term Period would extend beyond the Maturity Date, then the Strategy Value will be transferred to :T, the Guaranteed One-Year Fixed Rate Strategy. TERMINATION OF ENDORSEI+IEIVT The Company may cease to accept Premium PaYinerits, Transfers or renewals into this Crediting Rate Strategy. The Company may terminate this Endorsement at any time. Upon termination, the Owner cannot allocate any Prentiium Payments, : Transfers or renewals to this Crediting Rate Strategy. Unless notified by the Owner prior to the Endorsement's tet7ninauon •,? date, the Strategy Value of this Crediting Rate Strategy will be transferred to the Guaranteed One-Year Fixed Rate Strategy. This Endorserneni takes effect and ends with the Contract to which it is attached. Nothing contained in this Endorsement will be held to change, waive or extend any provisions of the Contract except as stated. ..., ?.n Seculary President WNICSP 1 YRPR-1205 WASHINGTON NATIONAL INSURANCE COMPANY Home Office: Chicago, Illinois Administrative Office: Post Office Box 7673, San Francisco, California 94120-7673 • Telephone (877) UO-7663 (Toll Free) S&P 500 INDEX ONE-YEAR MONTHLY AVERAGING WITH CAP STRATEGY ENDORSEMENT THE ENDORSEMENT This Endorsement establishes the S&P 500 Index One-Year Monthly Averaging With Cap Strategy for dte Contract to which it is attached. If the Endorsement and Contract define the same term, the definition contained in this Endorsement will apply. The terms of the Endonicti tt apply once the Owner allocates Premium Payments or Transfers into this Crediting Rate Strategy. Premium Payments, Transfers and renewals will be applied on the Allocation Dates determined by the Company. CONTRACT For purposes of this Endorsement, Contract refers to the individual annuity policy or to the annuity certificate issued under a group policy. ALLOCATION DATE The Allocation Date is the first day of the Tara Period. It is the date dec3ated by the Company for the allocation of each Premium Payromt, Transfer at re news) into this Crediting Rate Strategy. The Allocation Date occurs within 32 days after: a) the Company's Administrative Office receives the Premium Paytnertt; or b) the state of Transfer or renewal. INTEREST CREDITED The Company will calculate any interest to be credited and it witl be added to the Strategy Value only at the end of each " Term Period. The interest to be credited will be equal to the Strategy Value at the end of the Term ftriod before any interest ,. , .? is credited multiplied by the interest Crediting Rate. If the Owner Accesses a ptutiao of the Strategy Value before the end of 1=0 the Term Period, the portion Accessed will not be credited interest •.r -.1 INTEREST CREDITING RATE The interest crediting rate for this Crediting Rate Strategy will be the lesser of A or B. but not less than zero, where: t?J `p A equals: a Index Average, • divided by the Index Value on the Allocation Date, • minus one. B equals: 171 . Cap, CAP Cap is an interest rate declared by the Company for each Tetsrr Period under ibis Crediting Rate Strategy, used in the calculation of interest credited to this Crediting Rate Strategy. The Company vvy declare a new Cap on o1 before each Allocation Date, and it will remain unchanged daring the 'Germ Period. The Minimum Cap is shown on the Contract Data Page. INDEX The Index for this Crediting Rate Strategy is the S&P 540 Index. The S&P 500 Index does not reflect dividends paid on the stocks underlying the Index. If a) the publication of the S&P 500 Index is discontinued. or b) the calculation of the S&P 500 Index is changed substantially, then the Company will substitute another widely published Index. The Company will notify the Owner of the change. The Crediting Raw Strategy for the new Index will have a corresponding Cap. WNIC-SPMA-1205 INDEX AVERAGE. index Average is the average of the S&P 500 Index Valot for the 12 Index Dates. INDEX DATES Index Dates begin one month from the Allocation Uam. The Index Dates occur on the saute nurabered day each succeeding month as the Allocation Date. If the same munbcred day does not exist in a month, the Company will use the first preceding day that does exist. There ate 12 index Dates for each Term Period, INDEX VALUE The ]rrdex Value will be the closing value of the S&P 500 Index on 4 spcci#3ed date- If the index Value is not available for such date, the Index Value used for that date will be the Index Value an the first preceding trading day for which it is available. TERM PERIOD The Term Period is equal to 12 consecutive months, following tltt Allocation Date. It is used to m¢asure airy percentage change in the Index. TRANSFERS AND It1rWWALS The Owner may request a Transfer into this Crediting Rate Strategy from another Crediting Rate Strategy ar any time, subject to any limitations stated in that Crediting Rate Strategy Endorsement. Transfers are not allowed if the Term Period would expire after the Maturity Date. The owner may request a Transfer to another Crediting Rate Strategy, snbjeet to any limitations stated in that Crediting Rate 1z Strategy Endorsement. The Company's Administrative Office must receive cite Owner's request to Transfer from than I' ? Crediting Rate Strategy at least 7 days prior to the and of the Term Period. The Transfer will be processed at the end of the ?„ last Term Period. Transfers are not allowed during the Term Period. If a Transfer to another Crediting Rate Strategy is not requested, the Cornpaay will establish a new Term Period. The new Term Period will begin on the Allocation Date and will have a new corresponding Cap. If the Term Period is no longer r;P available or the Terre Period would extend beyond the Maturity Date, then the Strategy Value AV be transferred to the Guaranteed One-Year Fixed Rate Strategy. TERMINATION OF ENDORSEMENT The Company may cease to accept Premium Payments, Transfers or renewals into this Crediting Rate Strategy, The Company may terminate this Endorsement at any time. Upon termination, the 0-am a cannot allocate any Premium Payments, Transkrs or renewals to this Crediting Rate Strategy- Unlcss notified by the Owner prior to the Endorsement's termination date, the Strategy Value of this Crediting Rate Strategy will be transferred to the Gilarantted One-Year Fixed Rate Strategy, This Endorsement takes effect and ends with the Contract to which it is attached. Nothing contained in this Endorsement will be held to change, waive or extend any provisions of the Contract except as suited. Secretary President WNIC-SPMA-1205 WASHINGTON NATIONAL INSURANCE COMPANY Home Office, Chicago, Illinois Administrative Orrice: Post Office Box 7873, San Francisco, California 94130-7873 • Telephone (877) 549-7663 (Toil Free) ENDORSEMENT w w ICJ '> f Washington T'adonal lusuranee Company has issued this endorscment as a part of the Contract to which it is attached. For purposes of this endorsement, the term "Contract" rcfers to an individual annuity policy or w an annuity ccnificate issued under a group policy. if this Contract is replacing insurance or an annuity with any company, the Owner may cancel this Contract by returning it, with a written request to cancel, within 30 days after receipt to the Company's Administrative Office. After the Company receives this Contract and written request to cancel. the Company will refund any prerniurn paid within 15 days and void this Contract. Signed for the Company on the Effective Date_ Secretary President VMIC-830.1203 SUMMARY OF THE LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT AND NOTICE CONCERNING COVERAGE LIMITATIONS ANO EXCLUSIONS INTRODUCTION Residents of Pennsylvania who purchase life insurance, annuities, of health insurance should know that the insurance eornpanles licensed in this state to write these types of insurance are members of the Pennsylvania Life and Health Insurance Guaranty Association (PLHIGA). The purpose of this Association is. to assure that policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its oblgations. If this should happen, the Association will assess its other member insurance companies for the money to pay the claims of insured persons who live in Pennsylvania and, in some cases, to keep coverage in force. The valuable extra protection provided by these insurers through the Association is limited, however. As noted in the box below, this protection is not a substitute for consumers' care in selecting companies that are well- managed and financially stable. The Pennsylvania Life and Health Insurance Guaranty Association may not provide coverage for this policy. if coverage is provided, it may be subject to substantial limitations or exclusions, and require residency In Pennsylvania. You should not rally on coverage by the Pennsylvania Life and Health insurance Guaranty Association in selecting an insurance company or in selecting an insurance policy. ?r r? ?i ti „o coverage is NOT provided for your policy or any portion of it that is not guaranteed by the insurer or for which you have assumed the risk. Insurancee companies or their agents are required bylaw to give or send you this notice. However, insurance companies and their agents are prohibited by law from using the existence of the association to induce you to purchase any kind of insurance policy. This Information is Provided By: Pennsylvania Life and Health Pennsylvania lnsurarm Department insurance Guaranty Association Bureau of Consumer Services 290 King of Prussia Road 1300 Strawberry Square Radnor Station Bldg, Suite 218 Harrisburg, PA 17920 Radnor, PA 19087 (717) 787-2317 (610)!975-0572 SUMMARY The state law that provides for this safety-net coverage is called the Pennsylvania Ufa and Health Insurance Guaranty Association AGL Below is a bW summary of this law's coverages, exclusions and limits. This summary does not cover ail provisions of the law; nor does it in any way change anyone's rights or obligations under the act or the rights or oblgations of the Association. (Continued on Reverse Side) WOW 0106 (P{) Page 1 of 2 MA7M Covers Generally, indvlduals wilt be protected by the Pennsylvania t ife and Health Insurance Guaranty Asso"on If they live in this state and hold a life or health insurance contract. or an annuity. or if they hold certificates under a group }flee or health insurance contract, or annuity, issued by a member insurer. The beneficiaries, payees, or assignees of insured persons are protected as well, even # they five in another state- EYG.MWL From Coverane. Persons holding such policies or contracts are not protected by this Aswdeflon specific • IN- they are not residents of the State of Pennsylvania, except under certain very spec circumstances; • the insurer was not authorized or licensed to do business In Pennsylvania at the time the policy or contract was issued; • their pof;cy was issued by a nonprofit hospital or health service corporation (p g., the "Blue), an HMO, a fratemat benefit society. a mandatory state poaling plan, a mutual assessment company or similar plan in which the policyholder is subject to future assessments, or by an insurance exchange. The Association also does not provide coverage for. ' any policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk; • any policy of reinsurance (unless an asswnption certificate was issued}; associations or similar entities to the extent they are self- or uninsured Uxled plans of employers , (that is, not insured by an insurance company, even if an insurance company administers them}; interest rate yields that exceed an average rate; ,., ;M dividends; 1 '2) - . experience, rating credits; credits given in connection with the administration of s policy or contract; ;a 16 annuity contracts or group annuity certificates used by nonprofit Insurance companies to provide retirement benefits for nonprofit educational institutions and their employees. policies. contracts, certificates or subscriber agreements issued by a prepaid dental carve plan; • sickness and accident insurance when written by a property and casualty insurer as part of an automobile insurance contract; • unallocated annuity contracts issued to an employee benefit plan protected under the federal ?- On Pension Benefit Guaranty Corporation; financial guarantees, funding agreements or guaranteed investment contracts not containing mortality guarantees and not issued to or in connection with a specific employee benefit plan or governmental lottery; ' any kind of insurance or annuity, the benefits of which are exclusively payable or determined by a separate account required by the terms of such insurance policy or annuity maintained by the insurer or by a separate entity. ldmits On Anm-oua era The act also Omits the amount the Association is obligated to pay out. The Association cannot pay more than what the insurance company would owe under a poky of contract. Also, for any one insured I'ft, the Association wilt pay a maximum of $300,000 - no shatter how many policies and contracts there were with the 'same company, even if they . provided different types of coverages. Subject to the ovsr4) ,000 limit, the Association will pay up to $300,000 in life insurance death benefits but not more than $400,400 in net cash surrender or withdrawal values. For annuities, the Association will pay up to $300,000 in annuity beneft including $140,000 in net cash surrender or W%drawal benefits. For health insurance, the Associations will pay up to $100,000, including any net cash surrender or withdrawal benefits. CNIO63F 0106 CPA) 2 or2 {!V KAR-20-2007 TUE 09:37 AN FAX NO P. 21 )89838Ft3•FJ8 ToaL"a FMC GA P.2e8 MRR-1S 2m0t 1185 From??l 7377674798 . 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Avgv?* or di"n odud property (In wfigg my n vs) araVbk"st indmiV f. us not ptud s% dw power % b+ es fto at pwk or p lmdo tale for eA cer a partly far auk, r asa kuw for aap "dad of emu; la•'a 4r uqwc OOM dt alck pombaae% ev*mqp or tom; bay atialk l aato orgy p+ PMY as w5kh Y bn]damooti?plga. 2. Maooag?e,oapait.bnprRvt.uAwmip,r"WelAbr. wrl atUWM rat prop dr dmonltab +?r aota at delndap l+pat esdato eir soap irma+rst ion real . atm. rind rvsm Miw real ewe tinrea wad MMUMOM 4. gale= in Wb* orionp it w dgg to WMIe or apotrt 04 x3fi* fn %dslc or (n petit u d 06 = way mocOgp, a=w jbmwe, Ii m or adw cla M to od PW"- q 3 3 MAR-20-2007 TUE 05:38 AM FP.K NQ p29 )g8Bt43.FJB Pape 5 nW-15-WW 11:05 From=?A 71TM4?W To=LM FFU QA P.518 5. C>YBbT easafi??a$ dadiCp?G ta)1 ? Dutitiartimdtiida rmd t 1o1C1 I L ML IL a V 3 11 ?0 0 P Al $lC plsos, qOa*m of ww d=maaoe into amawft 6. )it $CQa?I, +t`A[{?`i? ? p4'pftf9 71Yith TgpdCt 1D I? ZC? prOpGt? 111 l oDald if&-top 1. Tbaamhori?ygsa?eed iatlrisPao?a?h?ll appl?to all real asfadein vdwch X bavm as bt-F Ietnde dso b0 twt umikdtn? i e,?ro?c ineamdiaLOwetA,Ue? 71omiduj& O=balaod GAY. Plmaa*am% and lawn aad aYmbWW as 7 Col*mbis Drive. C *W F= Ph TO a is tmv'bbparaw propetw p>mtatloas. To ska mw and 0 docmum accomy tn? umudo the tints io zomr ve ks. molrileboussndtemW tmikm To an is dads boad ow adw aecow t:m mwfiom To ad in cmumuft and opdm bumwdom. To tuba in bankiar and tires tray mcdo m •Pptdcc?aadaliwctloas?n?,guaioods'lxtcsanYm?Haac?i, bvtnat Gu6ing l'unibod?o, Impia bon& q To borrow rawayc r. ' 7Q ead?x ssfAdeA?it bmcus Q¢wided bowmn?s lbat my Agent slnsll aoe ptaAe any of . Grp 1 Wass in my *4 &posit bow X. To =PP in hmrm= UNON06ML t. Ta ?gp to retiRa?ear glom trsaoesdio?ns. U. To bAnWe b maf is in cgU= and t usts. V. 'Tn Pm $w dAb w arty! lWwddop 1w To $=Ave ge?v t bcncfa& X. To pmm bm nutk= Y- lb diwAs msrt< m to icy bdW with rcp=matdWc$ of to SWW Be=IV 4 XAR-20-2001 TOE 09:39 AM Fra?1s9EA mm-16-am 1,1196 FAX NO. ?17i'&74'M 7os1.M FAX 66% P.fYB ?y,,dn?gadiom?,awl totaioestty??l a>I?1Cb?itex?i0 U?ar$t0a fgctrv: f:mm?? SodA maky won and fw amp WIm waft x aaa Aftd w hb ft So" 3aao?gr.oaG,oonl. • To appalutaenommoragemd at tea. U -M MM EM. lA (3CAIT(7N R 7ifi paowarAd lor=*t by masos oflap a of *m b. I ?17111 owfim 21g the &o Aged w IIg doU 4o a C0mta be • x000ltnde?lbpTi+•t1erA1p0?YlEtC?A#dip/y:18p0?Wt?CttbatlgchAbIC?ORS11s?I aat ba subject to mW fiddW by 3idm of m5% of swb AqWs dediow, mm cir f to a4 A afvA6& *at be oemdushe amd Wo ft apmmt, mq pmoml ? Ledp atd aasi?. ? moovptb?. ?+aea dlmatSa.amloe of affto4 I spa to i i* oath ASmi4 and bold av4 Agwn bamdau. Ax m all c iho that ma be made *Ad= %A Agen& aw a noft of auah Agpot'a swinft hawaft, tai I bor*y v#W to nimbuft =a ASM in tiro =mat of air dammgas, ooan ud erpenxst w aaybe lmoud esa rtsalt dwy mb cUftL 3 a. 7W Poes k of Atsarew " be wvdW by my &bg to such Aow acmg tureut+dawfiten notlfoellariadt?r?os?iov??wi?idimtlxd?al?aot bca?zaaiderod 2 bwingun m a oguyxmhai. 1 2 rAs Pow= afAMmoy ie nwatodla two M aaoourpam arfvft& ibb is counk4 n No. / - ? n? wrr?ss Wao?oF,? ?al,? tr?bal?j?bou?, cbsv?atx?o ?oc,?y bid ? aud oral thus ORAL ayr o! Alt r JY . Z00?: G 8 cwt W. ogiwwwac' CON MrJNWRAY TK OF PS"YLV, M P. ? 4 couff r of Yo ^A 14 dog Df ,/Yt *A-4 7 Ong this, $e 6 2. r, beQost mc, tbb 5 MAR-20-2007 TUE 09:38 AM FAX NO. P. 26 sisBFD.FJB mw-l6-r''mT lit@7 FtatbIRM 71VW47A ToILM FAK OR P.7re mdadSod officer, pOdOo%' ekcpeaard c'i??' .aVJ t. 4' ?r O'Nki1?tOb0tbt W?IOSdbimC 50 e7?Cd?D?t ?l L.anda 01 :fie 8e mood tha e?ae tier t6a peotp?oexa thmein c?p6motL ' IN W1 WWS WHER F, I bmvmft sec my had and offidal deal. r?"?sw . ?t?mi wee. r i? 3 2 i? 10 7 4 3 3 6 . CZAR-20-2007 TUE 09:38 An FAX M A. 27 )3888BFO.i:JB 7177674M 7o=i!!CFib! QA P." LpARRVw.a oWm,HAVEREADTnjkTTACHWpDa-4Rof.AnOMyXN-f' 1 AM TM PER" MENTOW AS = AGW FOR, ' PRDRMI'A' L r tIIRM aC1C I)VAM(M TEAT IN To MSM40 0W A WHOM 1° W TO zWE CONTUly IN To PQW CLwATi V.M OR IN 7AIvLas. WIMN I ACT AS AUM. I SHALLEXOM TOPO'WM FORTHB W24MT OF THE PMCIPAL. X SBALY.ICF.EI?'j'HE A89HTS OF'i'H?PADJf1PAL SEp1SBA1'8 FRabdMYASi4ETS, i 5'FIAI.L 8' x?ASaNaai? c,Atrlu)N AN?3PxUD1aNCL. ' X B ALL XMP A MU AM ACCURATE ARCO= OF AU ACIYCM, 'M-" ANA )?I VISmoa '3 (W $13MW Of TNfi PRDXWAL.. PATIR! b 4 . 7 F xh?br+ S? M W-16-21x07 11:86 From: SEA 7177674790 So:LMG FAX GA P.1-,8 wasntngm Ivavown insuranoa lixmpa ny Aa6rrlAW Mlivr Officr. P. 0.1 r 1IN1216, Rome, 0A 30162.7216 Tckphottc (E77) 54547663 CUMMER SERVICE FORM To be ee"Uted by Iha pment Coatreet owbeKs) Conim,t Nw(a) VtJ f1 6 L3,j Q . nw(s) t.. J? 1 ^"? F R-EW MAR 1 6 2007 ' AA !l'1 ? tA: 1- owra-R p]M.ar nwke the rulluwing alrm?ges: 1. O Cbaata of Addre+? (Print the name of tits penant w>twa atddress is ettangini;) Street C$y State Zip Code Phone Number ( 1 !'lease aatet b%wc tax rcparling are fowra d6trihutlrlrt ondlor wilhliolding requests will be hated (>'rr your address of =Ord at the fune?ofdistribution. We recommend that you coreseilt your Lut advisnrregardirtg distfihuticus b m your anrwity. 2. IY ChsegrolBearflriary(ies)- Piease prM names in 1101L 1, the undeniped. hetatty revoke arty and all prior Ocnctkiary dcaignatiSn's and reyuot Washington National hwrrancc Company (-thL Company" hrmin) to change ilia $cmvffc ary(i%) under thee ahave numbered Contfact as follows, (Always jive !be )vase of Prbnary *acAdw7 and Contlakrat Up4dirlory as it ybuyld appear as our rootds,) Ifooly one berm ic9ery is elected and nn alkwAtim Is indicated, the allocatinn will dcfauk to 10056. If multiple btarcGuiarics are elected $urrfvTnjRenefiefariergfra?J,eiaas•ehap?kanr and wealloeulonkirdiested.Tilealkteatlonwill detliukto"sham equally". equnlJy aefsss rrrherwlse apae?•.d lftht Aa?urJMlnry ire a rharfr y. plrasr Y fht full lwnta. addra?i and tax lotrnriJltarfon number of &W ehnrfry. !f the beneficiary is a vwt. please inrlude the Ad# ofthe frurr. NANM R PLATIONSHIP TO OW-W-R '1'o ALLOCATION ? i"rirnary Iiteneticittry(ies) hG ?o??w r C ? ._ a oro? ? rj q Lt- r, u A t? C otr 1:4 to v N. ? ?tr. T' 33 ,?9./??' fr 33 oti Seer ? L'nntirtgant lieatefic'rary(ics) i 3. 0 lkatrest for lluplftatt (:antraet: 1 state that my contmut Ints barn iust ur desi" ed. 1 act ee to dclivt oti"`?tru r , to the Company without claim should it be lbund at a later date. 'Y?? 4. D Other Change l•a Pitmc ante the following change: _ S. (3 Request tar Service I bove a qucstiun about- Pkinm wmact me during the day td the fulluwbix Dhutie rnombcr The best time to contact me is:,_ Lit Sipnafurat . t srg?ee tltut my signature beluw shall apply W eeCh reQuest that tric hoe„ cornpilted on this tom. U? ^ /S- 0 7 Dare ti ntr Slat Irrevocable scttePWiary lSp uUI Sigauwr>r (1f any) J0111i Owner Sigumurc Orany) -- Spousal Sigmrturr' (iftepplicubic) * "xitoul Silpiuan r Wktd In totntnuomr hWcrty Stara: AZ. CA. U). LA. NM. NY, TX WA, ox] W1. If Spouse dots nots?n is Coartattnity A,Rv .'req Stile, the etMWW IAvner aftpwfedaes halt tic contract is not communlry ptoWrty. txkao ft cumprrry Iwo been noti&d of a aanrruintty Froperly tntam-itrthix PAW. *0 Eutaptmy He eatillad W i* oa its VW )ltih •betiefthata0 iueh lnterera etr)sts oral testwv.a,w wL*"iMIky ft WOvy. The Imeu ad mater eoattaet nwecr ¦igeieg this fomt agrees to InderroW and hold tic Coatpaty harerkay burn the uawcituaxas m' aogtpdrtg thb trtrosactiOrL fNl I1SF 1rI06 If347 tx ?l L I + r.:?? 11193 so UV 10 This is to certify that the infotmation here given is correctly copied from an original certificate of death dolly filed 'with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: it Is Illegal to duplicate this copy by photostat or photograph. ap? d"*Z' 47 r2AZ4'?' FCC for this certificate. $6.00 4, Local Registrar ~- - P -13352298--- - No. .ev 1wo jam me 'o`.."' WAR 212007 Date APR 0 9 2007 C71D LA 67 COMMONWEALTH OP PUMSYLVANIA - OMRTMM Of HEALTH • VITAL RKOR08 CERTIFICATE OF DEATH (S" Inalwellom and eump%& 9n nvMOy slate ILE taltW ar.K77wt i Beinho wor Pale 2 0 -26 -5212 March 17 2007 9m., i a a• rrr.am «Hw R rJ.m, INVOW ?«, Feb. 13. 1932 York County, PA D Oaaaawmw Dasa ? +.. meneb..Twstems __sswr - - ' a t e' cl Ilower Allen Twp 7 Columtii O fv White .MI a.rra? rnYK 113 Super. 1BEV?`4r n Du. lBw k 7 '°+" r+roIlatried Y Fr Nanc Y t?r?aClumbia Drive PA ?,.1r.®+l.sa&.u## Lower A1Len j 17011 p Hill r...a it c.r, Cumberland +?•O be ammor , + 4r t.. a t1 ra.l o n?...%r7e.,nwrower ,e ww.wraphadr+.awar,wrl Evelyn Jacoby "Plawffts im.wMtwel?aa.wl?.Lrr/>??.a1rW y w_ Seinhower Irv 285 Di Springs Road, , EtterS 'PA 17319 „a RA,rar, ?C..au. Oww. i,t pMR4m.laer lrmRan7rl T+.N.Rr Dllersea.arll?P,¢prnrl?,.?rlay C am 13 a.,.+b.,sr. rch 23, 2007 ollin Green Memorial Park Hill PA 7 ! f anp gte?lparpe.., aW dsts.a.' aY rrsw M ' 1i.+warwmrr arm ' -L F O Stones Murray Fri 408 3rd St New Cumberland, PA 17070 rnO.tMstananeMO >i>,r r rrie4almw7?l 1,rae?r,.t+ ai OwstiraGl.waalme waeo , nawra,ae?r 2-`/??'C L.. Rai 7 - M - d a.ya.r SIR . . Q 1 at _I 7 M hriel.r,rrR./.?a.Tp.n All. 7lsrMrw IWRSVMtO statQwPr.+arguerlmrwrronrtiairegrnsGMrwrCsmr? wsw?a.a 10 M• May-CAn (-7, 9,00 -7 Cla w 90 caMNsutmprararawr1"aarm" , Room, rr P"aso*mr NW& amp% rlraerrOWN tR, nrt er.t. -?em?lY?.Rr,M.m.e•??tr?O?IAtY??IOl NM1,a?,mM4Mtr YreCYmC O abom* NMM.Ry?NMMMR1.r?a.w Ml ?7m ?P ?r?r.m.:r.remartl?ap.aW YIMON tiwl tr?Naw r,rrsM. r yr1?1L?e „ers,r ni?'wm'ae?ij q?9QlA1' , IY?Tr1?1Ut't'!O 1??i1 1 1 ?R 'fi . ! .a t ? ra'q.r.mrtery? r ? r l . sl ra ll?Mm?rm.atat<111? 0 , ? ?'gMrtl?efaa f rmm IM?1'M fA1?F•t Oarh4ammmmlYAl ? MF7'?aM/7w.YUTaq. 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JJ I Kig NT r3 f ; r t t?r 1 t I I t ?+ se z , 2 to - 1f 14 17#a : . ;?? r E,x ki by'4 (Page 1 of 4) _ Conseco Insurance Company Washington National Insurance Company Administrative Off ANNUITY CLAIMANT STATEMENT VAR X0;07 Conseco Life Insurance Company hqkf P.O. Box 1982, Cannel, IN 46052-1982 APR 1Vn, Contract Number: LAC so 1. Full name of deceased annuitant: r4r 2. Full name of deceased owner (if other than above) 3. Is any interest in contract pledged or assigned? No Yes - please attach copy of assignment. -A: 4, N+thatperctntage,aLtttc.death,benefit;arcyou.claiming?:_ %. . - ?- •:? r:-A. NAME OF CLAIMANTIBENEFICIARY. (I?.., B. ADDRESS: ?A » o C. CLAIMANT'S SOCIAL SECURITY NUMBER:omplctc certification below) y? y D. DATE OF BIRTH: PHONE NUMBER: (Tih Sl???oSot V1 P: E. RELATIONSHIP TO DECEASED ?S - f C • G U? BenefitNew is the Company's primary method of payment for proceeds of S5000 or more. $enefitNow Is an interest bearing money-market type of account with check-writing privileges (see Included BenefitNow insert for more details). BenefitNow is not available In all states or all companies. If a BenefitNow account cannot be established a lump sum check will be issued. Specify a settlement option below only if different'from BenefitNow. If the Decedent was the owner of the contract: Open Claim (up to 5 years Annuitizadon/Lifetime payout (Must begin within 1, year of death) Spousal Continuation (if available) N) ,>ls t-? If the Decendent was the Annuitant: (on a contract where the death benefit is paid when the annuitant dies): Open Claim (up to 5 years only) Annuitization (must be elected within 60 days to avoid immediate taxation) Spousal Continuation (if available) If owner has designated a settlement option, we are required to carry out that designation it, (page 2 of 4) Canseaa ttn9111001 col"asny Conswo Loa lasumnoe Company of Texas Cortseco Ule Irurrrenoa Company ? Waahltplori f+farGo:tal Insw?ar?oe Company COASECO. Adntlaktrati+e Officer PA. amt 1484, Carinet. IN 46081-1482! Withholding Election and Taxpayer Certification (Substitute IRS form W?-p) Tax deferred eamings and any pretax prbrniums paid trio an Annuity contract are tmtable when the contract is surrendered. You are liable for FederaUStete taxes or the taxable portion of your benefits. Unless yet; tell us otherwise, FederellState Income taxes will be withheld, where applfcable. If you elect not to have withholding apply or If you do not have enough Federal income tax withheld, you may be responsible for payment of estimated ImL.You may inour petwittes under the estimated tax rides It your wilmolding and estimated tax e•r?? _. _.. .. -y il- iinit era nni stffGa?rd. Spousal'benetiF:ianes dray be se'jecl to mend ary ZD% wit he ing on Tax Sheltered Annalty (403(b)) and pardon contracts. NOTE; REGUTAR FEDERAL WrNHOLDtNG 1S AUTOMATICALLY10% IF NO ELECTION IS MADE ON LUMP SUM PAYMENTS. STATE WITHHOLDING . WILL BE BASED UPON STATE SPECIFIC REQUIREMENTS. Notes The election below may not be valid In those states that have mandatory withholding. Also, fryou are a non-resident %Men. you trust complete forth W411EN instead of making this election now and eDmplating the Taxpayer certification. If you do not went withholding to occur, where opting out Is permitted. please Indicate such by marking .beapproprig"seletxions below: C) U7 A? W N 1-s Ua Ulf 0) N) 1W o) 1 do not wart! Federal income tax withheld from my payment b)__-I do oo wart State income tax withheld from my payment Nate: If you wish a specific amount or percentage to be withheld, please indicate In the spaces below. We will honor your request, provided it does not conflict with applicable federal or due law. Sptxdred Federal Tax Election Sor % gpedrled State't'ax Efettlon i or % Taxpayer Identification Number. Social Security Number - ?aOR EIN,_,,, CMMF1CATiON - Under penalties of perjury, I certify that: 1. The number shown on this farm is my correcttsucpayer Identification number (or I am waldhgfor a timber io be Issaied to me,) and 21 am notsublectto backup withholding because (a) I am exempt from backupvelthiwiding, or (b) I have not bend nottlled by this Internal Revenue SaWke that I sun subject to backup withholding at a result of a failure to report all Interest of dividends, or (c) the IRS has notified me that I am no longer st6im to backup withho ldinir 3.1 am a U. S. person (lncluding a U,S. resident alien). NOTE: Cross out 1 above ff ypu have been notified by the IRS that you am subloct to backup withholding becausA you have underreported Interest or dividends on your sax return. AAUGN (rl6M (Page 3 of 4) Conseco Insurance Company _ Conseco Life Insurance Company Washington National Insurance Company 6q,* CONSECO. Administrative Office: 11.0. Box 1982, Carmel, IN 46082.1982 11) the claimant, hereby make claim to the Death Benefit payable under the provisions of the subject contract and agree that all papers called for by the Company shall be a part of this statement. The certified Death Cerlificale and Policy must be returned with this statement if not in the possession of the Company. If you are not in possession of the subject contract please complete the lost contract statement below. LOST OR DESTROYED CONTRACT STATEMENT 1,, liie`below signed claimant, hereby certify that the annuity contraet'identified on the reverse side hereof has been lost or destroyed and that said contract is not assigned, hypothecated or pledged in anyway whatsoever. I therefore warrant and agree that should the original be found or in any way come in my possession, I will return or cause the same to be returned to the company, its successors or assigns. It is distinctly understood and agreed that the original contract or certificate shall become null and void. Dated this day of Claimant's Signature 20 u1 N N ANY PERSON WHa, WITH THE INTENT TO DEFRAUD OR KINTOWII,'G THAT HE IS C-) FACILITATING A FRAUD AGALtiST ANY INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. Ut THE FORM MUST BE COMPLETED AND SIGNED IN INK BY THE PERSON OR PERSONS, WHO [ENDER THE TERMS OF THE CONTRACT, HAVE THE RIGHTS OF DEATH BENEFIT. THE INTERNAL REVENUE SBRVICE'DOES'NOT'REQUIRE YOUR-CONSENT TO AN - PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING Date 7' - J0 7 >w Claimant/Beneficiary Signature Pr: St. a L /?e E 8D ly LA Witness Signature Unless the Company has been notified of a community property interest in this contract, the Company shall be entitle(] to rely on its good faith belief that no such interest exists and assumes no responsibility for inquiry. The claimants signing this form agrees to indemnify and hold the Company harmless from the consequences of accepting this transaction. NO AGENT IS AUTHORIZED TO ALTER THE TERMS OF THE CONTRACT OR BIND THE COMPANY. jex k, ?, ?- 6- tBage 1 of Q) _ Cotsseco Insurance Company Conseco Life Insurance CompCE'' ED , r Washington National insurance Company w ? s MAY 010" SECO. Administrative Office: P.Q. Box 1982, Carmel, IN 46092.19 D LAO 50 ANNUITY CLAIMANT STATEirMENT Contract Number: _ MAXi96e dP.3y,7 1. Full name of deceased annuitant: CIA7.9 &FM /?OWItZ 2, Full name of deceased owner (if other than above) 3. Is any interest in contract pledged or assigned? NO Yes -- please attach copy of assignment. 4. What percentage of the death benefit are you claiin ing?: % A. NAME OF CLAIMANT/BENEFICIARY; ,641,9%da YU6 B. ADDRESS: C. CLAIMANT'S SOCIAL. SECURITY NCiMBER.R-_k- jy?Kcompiete certification bcia O) D. DATE OF BIRTH: PHONE NUMBER: (111t 2ya - MiDf 5 0 E. REL ATIONISHIP TO DECEASED 6MAth -))A l6hLT" 2 2 0 0 7 1 g 2 5 1 BenefitNow is the Company's primary method of payment for proceeds of $5000 or more. BenefitNow is an interest bearing money-market type of account with cbeck writing privileges (see included BesefitNow insert for more details). BenefitNow is not available in all states or all companies. If a BenetitNow account cannot be established a lump sum check will be issued. Specify a settlement option below only if different from BenefltNow. if the Decedent was the owner of the contract: Open Claim (up to 5 years only) Annuitization/Li fetime payout (Must begin within I year of death) Spousal Continuation (if available) If the Decendent was the Annuitant: (on a contract where the death benefit is paid when the annuitant dies): Open Claim (up to 5 years only) Annuitization (must be elected within: 60 days to avoid immediate taxation) Spousal Continuation (if available) If owner has designated a settlement option, we are required to carry out that designation (page 2 of 4) Comsm Insurance Compehy _ Conseco Ue Inwrthte Carnpany of Texas Consew IN Insurance Company _.,. Wntirtgft Naionar insurance ComDenY CONTSECO. AdroIlistratift ON= P-M nox 19e2, Cwm*l, IN 46M-19"2 Withholding Mectioh and Taxpayer Certification (Substitute IRS form W-A) Tax deferred earnings and any pretax premiums paid into an annulty contract are taxable whan the contract is surrendered. You are liable for Federal/Stele taxes on the taxable portion of your benefits. Unless you 181 us xtben*%e, FedemYState Income taxes will be withheld, where applicable. If you elect not to have withholding apply or If you do not have enough Federal income tax withheld you may be responsible for payment of estimated talc You may incur penalties ender the estimated tax rules 1; your withholding and estimated tax payments are not sufficient. Spousal beneficiaries may be subjed to mandatory 20% withholding on Tax Sheltered Annuity (4 03(b)) and pension c ntract% NOTE: REGULAR FEDERAL. WITHHOLDING IS AUTOMATICALLY 10% IF NO ELECTION IS MADE ON LUMP SUM PAYMENTS. STATE 1MTHHOLDING WILL BE BASED UPON STATE SPECIFIC REQUIREMENTS. Note: The election below may not be valid In those states that have mandatory withholding. Alto, If you are a non-resident alien, you must complete form W-88EN instead of mating this election now and completing the Taxpayer certMcation. if you do no: warn withholding to occur, where opting out Is petmltxed, please Indicate such by marking the appropriate selections below: I? 0 0 7 1 2 5 a) _l 42.M want Federal income tax vAhhetd 10orn my payment b) I do not want State ir=rne tax wltnhetd from my payment Note: if you wish a specific amount or percentage to be withheld, please indicate In the spaces below. We will honor your request, provided it does not conflict with applicable federal or state Jaw. Specified Federal Tax Election $ ,..-.?.?.or % Spedned Stem Tax Election $ or % Taxpayer Idehthixation Number. Soclal Security Nurnber g,,?) ; JJYPOR EIN CERTIFICATION - Under penalties of perjury, I certify that: 1. The number shown on this form Is my correct taxpayer Identification number (or I am waiting for a numberto be issued to me.) and 21 am not subject to backup withholding because (a) I am exempt from backup withholdinz or (b) I stave net been notified by the internal Revenue Service that I am subject to backup withholding at a result of a fathme to report all Interest of dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding. 3.1 am a U. S. person (Including a U.S. raident alien}. NOTE Cress out 2 above If you have been notilled by the IRS that you are subject to backup witbholding because you have underreported interest or dividends on your tax return. AA114HIR (DIf" (Page 3 of a) Conscco Life Insurance Company _ Consecv Insurance Company Washington National Insurance Company qk. CONSECO. Administrative Office: P.O. Box 1?K?, Carmel, IN 46082-1982 1, the claimant, hereby matte claim to the Death Benefit payable under the provisions of the subject contract and agree that all papers called for by the Company shall be a part of this statement. The certified Death Certificate and Policy must be returned with this statement if not in the possession of the Company. If you are not in possession of the subject contract please complete the lost contract statement below. LOST OR DESTROYED CONTRACT STATEMENT L the below signed claimant, hereby certify that the annuity contract identified on the reverse side hereof has been lost or destroyed and that said contract is not assigned, hypothecated or pledged in anyway whatsoever. I therefore warrant and agree that should the original be found or in any way come in my possession, I will return or cause the same to be returned to the company, its successors or assigns. it is distinctly understood and agreed that the original contract or certificate shall become null and void. Dated this day of 20 Claimant's Signature G 2 ANY PERSON WHO, Wrm THE 1N7ENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST ANY INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE 1 FRAUD. i THE FORM MUST BE COMPLETED AND SIGNED IN INK BY THE PERSON OR PERSONS, WHO i UNDERTHE TERMS OF THE CONTRACT, HAVE THE RIGHTS OF DEATH BENEFIT. 9 THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO - AVOID •BACKUP WITHHO . _ azz ArNL& Date 2 Claimant/Beneficiary Signatu 5 Witness Signature Unless the Company has been notified of a community property interest in this contract, the Company shall be entitled to rely on its good faith belief that no such interest exists and assumes no responsibility for inquiry. The claimant/s signing this form agrees to indemnify and hold the Company harmless from the consequences of accepting this transaction. NO AGENT IS AUTHORIZED TO ALTER THE TERMS OF THE CONTRACT OR BIND THE COMPANY. C,???br? .f_. (page 1 of Sy A. NAME OF CLAIM kW/BENEFICIARY: _54 L ` ??, ?, 14 h Q w f L B. ADDRESS: 2- `? 1?? ., 9 Y / 73l C. CLAIMANT'S SOCIAL SECURITY NUMBER: 74 -7? ?? (compicte certifit:ation below) ? q D. DATE OF B1RTH:3 J" r PHONE NUMBER: ?I) b _ Q E. RELATIONSHIP TO DECEASED h N a ' N W M Conseco Insurance Company Conseco Life lnsumncc Company Washington National Insurance Company b?. . CONSECO. Administrative Ofce: P.O. Box 1982, Carmel, IN 46082-1992 ANNUITY CLAIMANT STATEMENT Contraet Number: V r71Z ? ? Q 2 3 ? 7 1. Full name of deceased annuitant: - j'I 2. Full name of deceased owner (if other than above) 3. Is any interest in contract pledged orassigned? X___1\10 Yes -- please 3,1. attach copy of assignment. 4. What percentage of the death benefit are you claiming?: 3 -3 % C) BenefiitNow is the Company's primary method of payment for proceeds of 55000 or more. BenefolNow is an interest bearing money-market type of account with check-writing privileges (see included BenefitNow insert for more details). BeuefitNow Is not available in ail states or all companies. If a BenefitNow account cannot be established a lump sum check will be issued. Specify a settlement option below only if different from BenefitNow. If the Decedent was the owner of the contract: Open Claim (up to 5 years only) Annuitization/Lifetime payout (Must begin within 1 year of death) Spousal Continuation (if available) If the Decendent was the Annuitant: (on a contract where the death benefit is paid when the annuitant dies): Open Claim (up to 5 years only) Annuitization (must be elected within 60 days to avoid immediate taxation) Spousal Continuation (if available) If owner has designated a settlement option, we are required to carry out that designation (page 2 of 6) _Consew Insuranoe Company - Consece Ufa Insurance Company orTem Consew tee inaumm Company _,,, Wssh*WgW haJoW lnsuranoe Company CDA\TSECO. AdWaburat)va Cher PA.13ot M. Grand. IN 46M-14112 Withholding IJection and Taxpayer Certification (Substitute IRS form W-9) Tax deferred eamings and any pretax premiums paid into an annuity contract are Taxable when the contra(3 is sumendered. You are NBWe for Peierali tale taxes on the taxable portion of your benerds. Unless you tell us otherwise, FederoWStrrte Income taxes wIN be withheld, where applicable, (f you elect not io have withholding apply or If you do. not have enough Federal ioome tax Mthheld, you may be responslWe dor payment of estimated tax. You may kmr penalties under the estimated tax rules If your w0hol ft and estimated to payments are not sufficient. Spousal beneficiaries may be subject to mandatory 20% withholding on Tax Sheltered Annuily (403(b)) and pension contracts. NOTP- REGULAR FEDERAL WITHHOLDING is AUTOMATICALLY 10% IF NO ELECTION IS MADE ON LUMP SUM PAYMENTS. STATE WrMHOLDING WILL BE BASED UPON STAI c SPECIFIC REQUIREMEN i S. Note: The election below may not be valid in those somas that have mandatory withholding. Also, if you are a non-resident alien. you must cormplate form W-86EN Instead of making this election now and completing the Taxpayer certification. If you do not want withholding to occur, where opting out It permltted, please Indicate, such by marking the appropriate selections below: ha Q N Q N l?+ fti Uri N b a) _J do not want Federal income tax withheld trom my payment b) _l do not went State income tax withheld from my payment Note: If you wish x spedfic amount or percentage to be withhold, please indicate In the spaces below. We will honor your requem provided it does not condlict with applicable federal or state law. Specified Federal Tax Election S. Specified Stare Tax Slectlon S or. Taxpayer Identiftation Number: Social Security Nurnbert 7?_ r I - 7- 4 EIN CERTIFICATION - Under penalties of perjury, I certify brat: 1. The number shown on this form Is my correct taxpayer identllication number (or l am waiting for a 'number to be issued to me,) and 2 I am not subject to backup withholding because (a)1 aim exempt from backup withholding. or (b) I have not been notified by the Internal Revenum Service that i am sub)ect to backup withholding as a result of a fanur a to report all Interest of dividends, or (c) the IRS hats notified me that I am no lodger subject to backup withholding. 3.1 am a U. S. person (Including a 1,15& resident allen). NOTE Cross out 2 above tr yo u have been notified by the IRS that you are subject to backup withholding because you have underreported Interest or dividends on your tax return. AA134BN CDB/OS) (Sage 3 of 6) Conseco Insurance Company Conseco Life Insurance Company Washington National Insurance Company l . CONSECO. Administrative Officc: P.O. Box 1982, Carmel, IN 46082-1982 1, the claimant, hereby make claim to the Death Benefit payable under the provisions of the subject contract and agree that all papers called for by the Company shall be a part of this statement. The certified Death Certificate and Policy must be returned with this statement if not in the possession of the Company. If you are not in possession of the subject contract please complete the lost contract statement below. LOST OR DESTROYED CONTRACT STATEMENT 1, the below signed claimant, hereby certify that the annuity contract identified on the reverse side hereof has been lost or destroyed and that said contract is not assigned, hypothecated or pledged in anyway whatsoever. I therefore warrant and agree that should the original be found or in any way come in my possession, I will return or cause the same to be returned to the company, its successors or assigns. It is distinctly understood and agreed that the original contract or certificate shall become null and void. ;%? -? 4,/, / Dated this -- day of 20. 7 Q N N N I? N Claimant's Signature ANY PERSON WHO, WITH THE INTENT TO DEFRAUD OR KNOWING, THAT HE IS FACILITATING A FRAUD AGAINST ANY INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. THE FORM MUST BE COMPLETED AND SIGNED LN INK BY THE PERSON OR PEP'SONS, WHO UNDER THE TERMS OF THE CONTRACT, HAVE THE RIGHTS OF DEATH BENEFIT. THE INTERNAL REVENUE•SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING. Clairnant/Beneficiary Witness Signature MCI# -7 Unless the Compat?ras been notified of a community property interest in this contract, the Company shall be entitled to rely on its good faith belief that no such inicresl exists and assumes no responsibility for inquiry. The clairnant/s signing this form agrees to indemnify and hold the Company harmless from the consequences of accepting this transaction. NO AGENT IS AUTHORIZED TO ALTER THE TERMS OF THE CONTRACT OR BIND THE COMPANY. ?Xl,sbi ?' _L 07/31/2007 TUB 15:47 • PAX 71'72366919 • 2002/002 Thomas B. York, Esquire Phone: 717.236.YORK (9675) Facsimile: 717.236.6919 Email: tyork@yorklegalgroup.com Jacqueline 1VL Welby, Esquire Email: jwelby@yorldegalgroup.com July 25, 2007 (resent July 31, 2007) Edward McNamara Assistant General Counsel Bankers Life and Casual Company 222 Merchandise Mart Plaza. Chicago, Illinois 60654-2005 Re: Washington National Insurance Company Clair Beinhower VAR 000 2347 Dear Mr. McNamara: As you instructed via telephone, I am writing to advice you that the executrix of the estate of Claire Beinhower is asserting a claim in regard to the above-referenced annuity on behalf of her mother, Nancy Beinhower. The Executrix, Terri Cassel, intends to challenge- the change of beneficiary designation made on the policy in question, Wbich occurred two days before Mr. Beinhower's death. I am in communication with the Agent of the Power of Attorney who made the beneficiary designation change to request his cooperation in resolving this issue. If he refuses, I may request that your company agree to put the funds in the appropriate court though Petition for Interpleader. Very truly yours, Jacqueliue M. Welby JM'W/drg 3511 North Front Street - Harrisburg, Pennsylvania 17110-1438 ?x?, d? f S CHECK NO. 0002900410 ? MP WASHINGTON NATIONAL- INSURANCE COMPANY 1 11825 N. PENNSYLVANIA ST., CARMEL, IN 46M MELLON BANK N.A. PHILADELPHIA, PA 62-4 PAYABLE THROUGH MELLON BANK (DE) WILMINGTON, DE 311 PAY THIRTY-SIX THOUSAND, NINE HUNDRED SIXTY-TWO AND 461100 --------------------------------------------- DATE CHECK AMOUNT TO CLERK OF THE COURT OF COMMON PLEAS OF 08/24/2007 ******36,962.46 i THE CUMBERLAND COUNTY, PENNSYLVANIA , PA •:r:4:•:•}}}vY:}%•::irrrrrrv%i{•Yrrr»%ix:•asw:rrs:•wxi::,:Jx•:bahv{bi•}rrr: •: ORDER OF {4}}•.}}}•v.%•}U%!rX{4h:r:.{W%iAF%'•• '•••• iJhR}%+i{Jrb:?iN:?.{{47iJ%0.}:rri?•: S:4G}:GCJ}%• .u:{i?J%J:' vib. i? ACJ}}:Yk%C•}:iY Yr}iLY4% •}ru}:4:-:•:•%•i%r. •:•:•h'•V. x?•:•hw•.:•}:. •. }}.iv M}}:?4:4PQ4:S-07P:4.VW0a4MMGM •:{JY.?i??v%:?+.•}• •v:{4%vrtib}}: v%' '.M•AVSY:}}N%ivwr%;;wr%tvYfi%4%iIX476k:i-0: ...... :. ti{}}. ••}•4•ppQp% 'Y •:{rnti•}:4:4.ii{tiN%?•%•}: }:IXbi:ti:%•%iiv :•YM.•h^Y.•X?rib:<•Yfnvhv:{ d'i:•}l4Yr:::}}};.;:ypCi?{J}}}:J%960.W:7}kv. K?•:?•%?•%{Ji? ':J:J: :?•}W AN4%W.?•YAG%8S VOID AFTER 180 DAYS AUTHORIZED SIGNATURE 11.000 29004 100 1:0311,000471: 2em,969 9 2 Lill WASHINGTON NATIONAL INSURANCE COMPANY 108/24/; 00 nn00410 11825 N. PENNSYLVANIA ST., CARMEL, IN 46032 VENDOR#: PAYEE: CLERK OF THE COURT OF COMMON PLEAS OF POL/AGT#: VAR0002347 PROCEEDS ON DEATH OF CLAIR W BENHOWER TOTAL36, 962.46 WNIC /090PA/ 7003/ MEL- P 00 00 T.,_M f 1 ~ C3 ' r _`:f r `? NOV-08-2007 THU 04:56 PM FAX NO. 717 755 4708 P. 02 • IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA WASHINGTON NATIONAL INSURANCE COMPANY, Plaintiff VS. BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower Defendants Civil Action - Law No. 076648 CIVIL TERM ACCEPTANCE O SERVICE I, JACQUELINE WELBY, Esquire, accept service of the Complainton behalf of Terri Cassel, Executrix of the Estate of Clair Beinhower, and certify that I am authorized to do so. Date: -//-/1-017 d i a -4K-- F . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA WASHINGTON NATIONAL INSURANCE COMPANY, ; Plaintiff vs. Civil Action - Law No. 07-6648 CIVIL TERM BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, : NANCY BEINHOWER, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower Defendants PRAECIPE TO THE PROTHONOTARY: Please reinstate the Complaint which was originally filed of record on November 1, 2007. Date November 30, 2007 Respectfully Submitted: KAGEN, MACDONALD & FRANCE, P.C. Dougla P. France, Esquire Attorney ID No. 84744 2675 Eastern Boulevard York, PA 17402-2905 Phone: (717) 757 - 4565 _) ^ .?,, C: ? ? u '7 O ? ?Y??, ?' Q ? r- a ,?' ? L'w -.?? WASHINGTON NATIONAL INSURANCE COMPANY Plaintiff BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower Defendants : IN THE COURT OF COMMON PLEAS, : CUMBERLAND COUNTY, PENNSYLVANIA : CIVIL ACTION - EQUITY No.: 07-6648 CIVIL TERM PRAECIPE FOR NOTICE OF ENTRY OF APPEARANCE TO THE PROTHONOTARY: Kindly enter the appearance of Jacqueline M. Welby, Esquire on behalf of Terri Cassel, regarding the above-referenced case. A copy of all notices pertaining to this matter should be sent to Jacqueline Welby, Esquire at 3511 North Front Street, Harrisburg, PA 17110. Respectfully submitted, THE YORK LEGAL GROUP, LLC c: c `1) ' __Jacqueline M. Welby, Esquire U Attorney I.D. No. 57678 3511 North Front Street Harrisburg, PA 17110 (717) 236-9675 Fax: (717) 236-6919 Email: iwelby@yorkleizalp-,rout).com Attorney for Terri Cassel Date: December 18, 2007 CERTIFICATE OF SERVICE I, Jacqueline M. Welby, hereby certify that on this 18th day of December, 2007, I served a true and correct copy of the Praecipe for Notice of Entry of Appearance via U.S. First Class Mail, upon the following: Stephen K. Portko, Esquire Bratic & Portko 101 South U.S. Route 15 Dillsburg, PA 17019 Douglas P. France, Esquire Kagen, Macdonald & France, P.C. 2675 Eastern Boulevard York, PA 17402 4queline M2 0 rte ? r-? © i'r'i S -n L ; rn m lC} O ON WASHINGTON NATIONAL INSURANCE COMPANY, Plaintiff : BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower Defendants IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - EQUITY No. 07-6648 CIVIL TERM DEFENDANT TERRI CASSEL'S AMENDED ANSWER TO COMPLAINT FOR EQUITABLE INTERPLEADER AND NOW, comes Defendant Terri Cassel, in her capacity as Executrix and as Power of Attorney for Nancy Beinhower, by and through her counsel, Jacqueline M. Welby, Esquire, and responds to Plaintiff's Complaint as follows: 1. Admitted. 2. Admitted. 3. Admitted. 4. Admitted in part. Denied in part. It is admitted that Courtney Meyers resides at 555 Hillcrest Road, York, York County, Pennsylvania 17011. It is denied that Courtney Meyers is an adult. By way of further answer, Courtney Meyers is a minor of six (6) years of age. 5. Denied. Nancy Beinhower resides at 4831 East Trindle Road, Mechanicsburg, Pennsylvania 17055. By way of further answer; Mrs. Beinhower's children Terri Cassel and Jeffrey Arnold serve as co-agents pursuant to a power of attorney. 6. Admitted. By way of further answer, Terri Cassel serves as co-agent for her mother, Nancy Beinhower. 1 h 7. Admitted. 8. Admitted. 9. Admitted. 10. Admitted. 11. Admitted. 12. Admitted. 13. Admitted. 14. Admitted. 15. Admitted. 16. Admitted. 17. Admitted. 18. Admitted. 19. Admitted. 20. Admitted. 21. Admitted. 22. Admitted. 23. Denied. After reasonable investigation, Defendant is without sufficient information to determine the accuracy of the averments of this paragraph and such averments are 2 therefore denied. By way of further answer, the averments of this paragraph are denied as a conclusion of law to which no response is required. Respectfully submitted, J line V. Welby, Esquire aC T YORK LEGAL GROUP, LLC 3511 North Front Street Harrisburg, PA 17110 Tel: 717.236.9675 Fax: 717.236.6919 Email: iwelby(&yorklegal roup.com Dated: December 18, 2007 3 r CERTIFICATE OF SERVICE I, Jacqueline M. Welby, Counsel for Petitioner of the Estate of Clair Beinhower, deceased, hereby certify that on this 18th day of December, 2007, I served Defendant Terri Cassel's Amended Answer to Complaint for Equitable Interpleader, via U. S. Mail, postage prepaid, upon the following: Stephen K. Portko, Esquire Bratic & Portko 101 South U.S. Route 15 Dillsburg, PA 17019 Douglas P. France, Esquire Kagen, Macdonald & France, P.C. 2675 Eastern Boulevard York, PA 17402 //? X- ?Cf?- * Ld Jacq ne Nf/Welby, Esquire 4 . i w VERIFICATION I, Jacqueline M. Welby, Esquire, do hereby verify that I am the attorney of record for the pleading party herein, and that the facts set forth in the foregoing Amended Answer to the Complaint are true to the best of my knowledge, information and belief, upon information supplied by Plaintiff. The verification of Defendant, Terri Cassel, could not be obtained in time for this filing. I understand that false statements made herein are made subject to the penalties of 18 Pa.C.S.A. §4904 relating to unworn falsification to authorities. Ja4uoline elby, Esquire Dated: December 18, 2007 5 ,' i Cn -n OUT Vol -tea CM t3 %Pr O =t4? . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA WASHINGTON NATIONAL INSURANCE COMPANY, Plaintiff V. BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSELL, Executrix of the Estate of Clair Beinhower, Defendants CIVIL ACTION - EQUITY NO. 07-6648 CIVIL TERM NOTICE TO PLEAD TO: Douglas P. France, Esquire Attorney for Washington National Ins. Co. KAGEN, MCDONALD & FRANCE, P.C. 2675 Eastern Boulevard York, Pennsylvania 17402 You are hereby notified to file a written response to the enclosed ANSWER AND NEW MATTER OF DEFENDANTS' BARRY BEINHOWER, NANCY ROGOWICZ AND COURTNEY MYERS within twenty (20) days from service hereof or a judgment may be entered against you. Dated: 2e-w,???az- ?`t, ??-?' k--i Stephen K. Portko, Esquire Supreme Ct. I. D. #34538 101 South U.S. Route 15 Dillsburg, PA 17019 (717) 432-9706 1 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA WASHINGTON NATIONAL INSURANCE COMPANY, Plaintiff V. BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSELL, Executrix of the Estate of Clair Beinhower, Defendants CIVIL ACTION - EQUITY NO. 07-6648 CIVIL TERM DEFENDANTS' BARRY BEINHOWER, NANCY ROGOWICZ AND COURTNEY MYERS, ANSWER WITH NEW MATTER TO PLAINTIFF'S COMPLAINT PREL 1. Admitted. 2. Admitted. 3. Denied. On the contrary, Nancy Rogowicz is an adult individual residing at 2957 Herrlyn Court, Dallastown, PA 17313. 4. Denied. On the contrary, Courtney Myers is the minor child of Nancy Rogowicz and resides with her mother at 2957 Herrlyn Court, Dallastown, PA 17313. 5. Admitted. 6. Admitted. 7. Admitted. 8. Admitted. 9. Admitted. 10. Admitted. 11. Denied. On the contrary, several weeks before Clair Beinhower died, he 2 had contacted WNIC's agent, Rocco Capuano Jr. CEP, RFC to notify them of his failing health and that he wanted to change the beneficiary of the annuity. Further, Clair Beinhower notified the insurance agent that he had executed a power of attorney naming his son, Barry Beinhower, as agent, and that he authorized his son to assist him and sign any forms on his behalf regarding the annuities. The insurance agent mailed the forms to Clair Beinhower's residence, however, these forms never got delivered to Clair Beinhower or his son, Barry Beinhower, which caused a delay in changing the forms. As a result, new forms had to be sent and then the insurance agent, Rocco Capuano Jr. CEP, RFC, met with Clair Beinhower in person on March 15, 2007 to go over the forms and review the changes that Clair Beinhower wanted to make. The insurance agent then filled in and completed the forms according to Clair Beinhower's instructions and wishes. Upon completing the forms, which named Nancy Rogowicz, Courtney Myers and Barry Beinhower as equal beneficiaries of the annuity in question, the insurance agent confirmed Clair Beinhowers authorization and consent and then the forms were signed in the presence of Clair Beinhower by Barry Beinhower, by the power of attorney. 12. Admitted. 13. Admitted. 14. Admitted. 15. Admitted. 16. Denied. After reasonable investigation, Defendants are without knowledge or information sufficient to form a belief as to the truth or falsity of the averment contained in paragraph 16 of the Complaint and therefore deny the allegations thereof. By way of further answer, Defendants believe and therefore aver that Terri Cassel's initial contact was to determine the status of the change of beneficiary of the Annuity Proceeds naming her as a beneficiary. 17. Denied. On the contrary, WNIC notified Defendant Barry Beinhower that the change of beneficiary by Clair Beinhower on March 15, 2007 was accepted and that application for benefits by Barry Beinhower, Nancy Rogowicz and Courtney Myers was approved. Thereafter, WNIC distributed the Annuity 3 Proceeds to Defendants by mailing the check but later stopped payment of the check. 18. Denied. On the contrary, WNIC stopped payment of their check to Defendants after admitting liability for payment of the Annuity Proceeds. 19. Denied. On the contrary, WNIC stopped payment of their check to Defendants after admitting liability for payment of the Annuity Proceeds. 20. Denied. The allegations contained in paragraph 20 contain mere conclusions of law to which no response is required. By way of further answer, WNIC has admitted the claim of, or subjected itself to independent liability to Barry Beinhower, Nancy Rogowicz and Courtney Myers, with knowledge that an inconsistent claim would be later asserted against it by any known or unknown person 21. Denied. The allegations contained in paragraph 21 contain mere conclusions of law to which no response is required. By way of further answer, WNIC has admitted the claim of, or subjected itself to independent liability to Barry Beinhower, Nancy Rogowicz and Courtney Myers, with knowledge that an inconsistent claim would be later asserted against it by any known or unknown person 22. Denied. On the contrary, WNIC has admitted the claim of, or subjected itself to independent liability to Barry Beinhower, Nancy Rogowicz and Courtney Myers, By way of further answer, the right to interest begins at the time payment is withheld after it has been the duty to make such payment." Schiller v. Royal Maccabees Life Ins. Co., 2000 Pa. Super. 265, 759 A.2d 942 (Pa.Super. 2000), citing Fernandez v. Levin, 519 Pa. 375, 548 A. 2d 1191, 1193 (Pa. 1988) 23. Denied. On the contrary, WNIC has admitted the claim of, or subjected itself to independent liability to Defendants and, thus, Plaintiff's request for costs and fees should be denied. WHEREFORE, Defendants respectfully request this Court to deny the request of WNIC to interplead this matter or to collect costs and fees from the Annuity Proceeds. 4 NEW MATTER 24. Defendants hereby incorporate paragraphs 1-23 above as if the same were fully set forth herein at length. 25. Rocco Capuano Jr. CEP, RFC, the agent for WNIC, met with Clair Beinhower in person on March 15, 2007 to go over the forms and review the changes that Clair Beinhower wanted to make for the Annuity Proceeds. 26. The insurance agent then filled in and completed the forms according to Clair Beinhower's instructions and wishes. Upon completing the forms, which named Nancy Rogowicz, Courtney Myers and Barry Beinhower as equal beneficiaries of the annuity in question, the insurance agent confirmed Clair Beinhowers authorization and consent and then the forms were signed in the presence of Clair Beinhower by Respondent, as Agent. 27. WNIC and its agents accepted the change of beneficiary form completed on March 15, 2007 and then approved the claim submitted by Barry Beinhower, Nancy Rogowicz and Courtney Myers for distribution of the Annuity Proceeds to them. 28. WNIC and its agents sent payment of the Annuity Proceeds to Barry Beinhower but then stopped payment of their check after admitting liability to the claimants. 29. WNIC has admitted the claims of Defendants Barry Beinhower, Nancy Rogowicz and Courtney Myers, with knowledge of an inconsistent claim, by stating through its agent that any claim by Terri Cassel on behalf of Nancy Beinhower, had been rejected. 30. The court may deny the petition if WNIC has admitted the claim of, or subjected itself to independent liability to any claimant, with knowledge that an inconsistent claim would be later asserted against it by any known or unknown person." Pa.R.C.P. 2306(a)(2), see also Lewandowski v. Life Ins. Co. of North America, 415 Pa. Super at 298, 608 A.2d at 1089 (stating interpleader should be denied where the petitioner has incurred independent liability to either of the claimants). 5 WHEREFORE, Defendants respectfully request this Court to deny the request of WNIC to interplead this matter or to collect costs and fees from the Annuity Proceeds. Dated:- 2K)X,---7 Respectfully submitted Stephen K. Portko, Esq. #34538 Bratic & Portko 101 South U.S. Route 15 Dillsburg, PA 17019 (717) 432-9706 6 i VERIFICATION I, Barry Beinhower, hereby acknowledge that I have read the foregoing, and the facts stated therein are true and correct to the best of my knowledge, information and belief. I understand that any false statements herein are made subject to penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. Date: ' 19 -0 A ..e CERTIFICATE OF SERVICE HEREBY CERTIFY that a true and correct copy of the foregoing Preliminary Objections was furnished by U.S. Mail, first class, postage prepaid on this 20th day of December, 2007, to: Douglas P. France, Esquire KAGEN, MCDONALD & FRANCE, P.C. 2675 Eastern Boulevard York, Pennsylvania 17402 Attorneys for Plaintiff Jacqueline M. Welby, Esquire THE YORK LEGAL GROUP, LLC 3511 North Front Street Harrisburg, PA 17110-1438 Attorney for Terri Cassel and Nancy Beinhower Dated: t , -r 2Q)-7 C'3-0'e-? Stephen K. Portko, Esq. #34538 Bratic & Portko 101 South U.S. Route 15 Dillsburg, PA 17019 (717) 432-9706 7 0 N Q ?b DTs ? rTl ?? ?, ?? ? x+777 SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2007-066J8 P COMMONWEALTH'OF PENNSYLVANIA: COUNTY OF CUMBERLAND WASHINGTON NATIONAL INSURANCE VS BEINHOWER BARRY ET AL R. Thomas Kline Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT to wit: BEINHOWER BARRY but was unable to locate Him in his bailiwick. He therefore deputized the sheriff of YORK County, Pennsylvania, to serve the within COMPLAINT & NOTICE On December 14th , 2007 , this office was in receipt of the attached return from YORK Sheriff's Costs: So answ Docketing 18.00 Out of County 9.00 Surcharge 10.00 R. Thomas Kli Dep York County 74.89 Sheriff of C mberland County Postage 4.94 116.83 12/14/2007 KAGEN MACDONALD FRANCE Sworn and subscribe to before me this day of A. D. SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2007-066.48 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND WASHINGTON NATIONAL INSURANCE VS BEINHOWER BARRY ET AL R. Thomas Kline Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT to wit: ROGOWICZ NANCY but was unable to locate Her in his bailiwick. He therefore deputized the sheriff of YORK County, Pennsylvania, to serve the within COMPLAINT & NOTICE On December 14th , 2007 , this office was in receipt of the attached return from YORK Sheriff's Costs: So answ Docketing 6.00 Out of County .00 Surcharge 10.00 R. Thomas Kline .00 Sheriff of Cumberland County .00 n 16.00 ?/'jOIC ? 7 12/14/2007 KAGEN MACDONALD FRANCE Sworn and subscribe to before me this day of A. D. SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 200,7-06948 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND WASHINGTON NATIONAL INSURANCE VS BEINHOWER BARRY ET AL R. Thomas Kline , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT to wit: MYERS COURTNEY but was unable to locate Her deputized the sheriff of YORK in his bailiwick. He therefore serve the within COMPLAINT & NOTICE County, Pennsylvania, to On December 14th , 2007 , this office was in receipt of the attached return from YORK Sheriff's Costs: Docketing Out of County Surcharge 6.00 .00 So answers: 10.00 R. Thomas Kline .00 Sheriff of Cumberland County .00 16.00 ? / -?`?a? 7 12/14/2007 KAGEN MACDONALD FRANCE Sworn and subscribe to before me this day of A. D. SHERIFF'S RETURN - NOT FOUND CASE NO: 20,07-06648 P COMMONTWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND WASHINGTON NATIONAL INSURANCE VS BEINHOWER BARRY ET AL R. Thomas Kline ,Sheriff or Deputy Sheriff, who being duly sworn according to law, says, that he made a diligent search and inquiry for the within named DEFENDANT BEINHOWER NANCY but was unable to locate Her in his bailiwick. He therefore returns the COMPLAINT & NOTICE NOT FOUND , as to the within named DEFENDANT , BEINHOWER NANCY 7 COLUMBIA DRIVE CAMP HILL, PA 17011 7 COLUMBIA DRIVE CAMP HILL IS VACANT. Sheriff's Costs: Docketing Service Not Found Surcharge ,.9 So answers* 6.00 14.40 -' 5.00 R. Thomas Kline 10.00 Sheriff of Cumberland County .00 35.40 KAGEN MACDONALD FRANCE 12/14/2007 Sworn and Subscribed to before me this day of A. D. F I OF 3. COUN 'TY OF YORK OFFICE OF THE SHERIFF 45 N. GEORGE ST., YORK, PA 17401 SERVICE CALL (717) 771-9601 SHERIFF SERVICE WSTRUCTIONS PROCESS RECEIPT and AFFIDAVIT OF RETURN PLEASE TYPE ONLY LME 1 THRU 12 DO NOT DETACH ANY COPES 1 2 COURT NUMBER Washington National Insurance Company - 0 0 4 0 civil 4. TYPE OF WRIT OR COMPLAINT 3. DEFENDANT/S/ Barry Beinhower et al Complaint AND N O T I C E SERVE 5 NAME OF INDIVIDUAL, COMPANY. CORPORATION, ETC TO SERVE OR DESCRIPTION OF PROPERTY TO BE LEVIED. ATTACHED, OR SOLD Barry Beinhower q-? T5 --er119 6. ADDRESS (STREET OR RFO WITH BOX NUMBER. APT NO., CITY, BOR . TWP. STATE AND ZIP CODE) AT 285 Big Springs Road, Etters, PA 17319 7. INDICATE SERVICE: M PERSONAL 0 PERSON IN CHARGE XCXDEPUTIZE -.1 CERT MAIL G 1 ST CLASS MAIL U POSTED U OTHER NOW November 8 20 07 I, SHERIFF O TY, PA, do hereby deputize the sheriff of York COUNTY to execute this. Writ-gnd make return therRAf•according to law. This deputization being made at the request and risk of the plaintiff.-- SHERIFF OF COUNTY 8. SPECIAL INSTRUCTIONS OR OTHER INFORMATION THAT WILL ASSIST IN EXPEDITING SERVIr T OF COUNTY Cumberland Please mail return of service toVV Cumberland County Sheriff. Thank y ADV FEE PAID BY ATTY. NOTE: ONLY APPLICABLE ON WRIT OF EXECUTION: N.B. WAIVER OF WATCHMAN - Any deputy sheriff levying upon or attaching any property under within writ may leave same without a watchman, in custody of whomever is found in possession, after notifying pe n of levy or attac^hrr1ls1`?t, without liability on the part of such deputy or Me sheriff to any plaintiff herein for any Ws, destruction, or removal of any property before sheriffs sale thereon I / 1 \ 1 9. TYPE NAME and ADDRESS of ATTORNEY / ORIGINATOR and SIGNATURE f \)4 L4_4 _ n f , 10. TELEPHONE NUMBER 11. DATE FILED Douglas P. France, 2675 Eastern Boulevard, York, k&,,)17402 757-4565 ? 1-1- 2007 12. SEND NOTICE OF SERVICE COPY TO NAME AND ADDRESS BELOW: (This area must be completed d notice is to be mailed). Doulgas P. France, Esquire, 2675 Eastern Boulevard, ?YorkE RFJm-A N I7a S H E R I F F SPACE BELOW FOR USE OF THE SFERFF - DO NOT WRITE BELOW THIS LM 13. 1 acknowledge receipt of the writ 14. DATE RECEIVED 15. Expiration/Hearing Date or complaint as indicated above. M J M C G I L L Y C S O 111-13-2007 112-1-2007 16. HOW SERVED: PERSONAL' RESIDENCE POSTED( ) POE ( ) SHERIFF'S OFFICE ( ) OTHER ( ) SEE REMARKS BELOW 17. e 1 hereby certify and return a NOT FOUND because I am unable to locate the individual, company, etc. named above. (See remarks below.) 23. Advance Costs 15 0.0 0 24. Service Costs o 3 0 25 N/F 26. Mileage 27. Postage 28. Sub Total 29. Pound 1 30 Notary 31. Surchg. 32. Tot. Costs 33 Costs Due Refund Check No • c c o , ?9 1 l 34. Fontign County Costs 35. Advance Costs 36 Service Costs 37. Notary Cert. 38. Mileage/Postage/Not Found 39. Total Costs 40. Costs Due or Refund 41. AFFIRMED SO ANS RS 42. day of 44. Signature of Dep. Sheriff 7 a 44 J 45. l? " 0 N©TA IA !NOTARY LISA L. BOWMAN NOTARY PUSLIC ? 46. Signature of York 47. GATE , CITY OF YORK; YORK COUNTY MY COMMISSION EXPIRSO AU, 1?f?66? County Sheriff WILLIAM M. H OSE, SHERIFF 12-6-2007 48. Signature of Foreign 49 DATE County Sheriff vc.? yr ?c ancmrr a mr- i unn anjmA i unr 151. DATE RECEIVED OF AUTHORIZED ISSUING AUTHORITY AND TITLE 1. WHITE - Issuing Authority 2. PINK - Attorney 3. CANARY - Sheriff 'S Office 4. BLUE - Sherdrs Office t 7 i a ` L ,_ tit I l i ?.. r 2 OF 3 COUNTY OF FORK OFFICE OF THE SHERIFF 45 N. GEORGE ST., YORK, PA 17401 SHERIFF SERVICE RECEIPT and AFFIDAVIT OF RETURN SERVICE CALL (717) 771-%Ol s i mu p1.E? ?T P A?.Y Ainr coPs Z COURT6NUMBER ??I'? PROCcGss 7 OR CO^TiCE MIRPORATION, ETC TO SERVE OR DESCRIPTION OF PROPERTY TO BE LEVIED, A - b ogowicz, 555 Hillcrest Road, York, PA 17403 6. ADDRESS (STREET OR RFO WITH WkN1 @R, APT NO., CITY, BORO, TWP, STATE AND ZIP CODE) "$6A, PA 17403 NAl U PERSON IN CHARGE EPUTIZE L) CERT RMAIL O ?ST CLASS PWAIL ' u Fwdlsfeb NOW Nnvem er 8 20 07 I, SHERIFF OF y COUNTY, PA, do hereby deputize the sheriff of ynrk COUNTY to execute this Wit artod eke return thW cording to law. This deputization being made at the request and risk of the plaintiff. 8. SPECIAL INSTRUCTIONS OR OTHER INFORMATION THAT WALL ASSIST IN EXPEDITING SERVICE.'. OF COUNTY Cumber Please mail return of service to Cumberland County Sheriff. Thank you. ADV FEE PAID BY ATTY NOTE: ONLY APPLICABLE ON WRIT OF EXECUTION: N.B. WAIVER OF WATCHMAN - Any deputy sheriff levying upon or attaching any property under within writ may leave same without a watchman. in custody of whomever is found in possession, after notifying person of levy or attachment, without liability on the part of such deputy or the sheriff to any plaintiff herein for any loss, destruction, or removal of any property before shenfrs sale they t. 9. TYPE NAME and ADDRESS of ATTORNEY / ORIGINATOR and SIGNATURE 10. TELEPHONE NUMBER 11. DATE FILED Douglas P. France, 2675 Eastern Blvd., York, 17402 757-4565 6-1-2007 12. SEND NOTICE OF SERVICE COPY TO NAME AND ADDRESS BELOW. (This area must be completed it notice is t o be mailed). CUMBERLAND CO S H E R I F F Douglas P. France, Esquire, 2675 EAstern Boulevard, York, PA 17402 an&f%V ncv nw inn uec nr Ysr cssrnama _ nn unT s..ffsrir'lc nrs psis ?..c . nr 1J. I acitnowleage receipt of the writ 14. DATE RECEIVED 115. Expirati(WHearing Date or complaint as indicated above. m.1 M r G T I I v r C n i i e 13n r 1 o 1 o n n -s 22. 23. Advance Costs 24. Service Costs 25. N/F 26. Mileage 27. Postage 28. Sub Total 29. Pound 30. Notary 31. Surchg. 32. Tot. Costs 33 Costs Due or Refund Check No U. Foreign County Costs 35. Advance Costs 36. Service Costs 37. Notary Cert. 38. MieagdPo5lagdNol Found 39. Total Costs 40. Costs Due or Refund 6th 41 AFFIRMED WERS . 42. d of 44. Signature of fil S u I 45 I Zd 7 o NOTA IAL ?/ NOTARY LISA L. BOWMAN, NOTARY PUBLIC YORK COUNTY CITY OF YORK 46. of York . iggnaa e County Sheriff L I M .? ---- _ 47. DATE , W L IAM . HOSE, SHERIFF 12-6-2007 2009 MY COMMISSION EXPIRES AUG 12 . , 48. Signature of Foreign - 49 DATE County Sheriff ae. I A%.NVNVVLGUksC Kr%.tIr I Ur I Mt bMtKIrr J Kt I UKN blia I UKE 151 DATE RECEIVED OF AUTHORIZED ISSUING AUTHORITY AND TITLE 1. WHITE - Issuing Authority 2. PINK - Attomey 3. CANARY -Sheriff's Office 4. BLUE - Sheni fs Office 16. HOW SERVED: PERSONAL RESIDENCE ( j POSTED( ) POE ( ) SHERIFF'S OFFICE p# OTHER( ) SEE REMARKS BELOW 17. 0 1 hereby certify and return a NOT FOUND because I am unable to locate the individual, company, etc. named above. (See remarks below.) 16. NVVANO TITLE O DIVIDUAL SERVED/ LIST ADORES HERE IF NOT SHOWN ABOVE (Relationship to Defendant) 19. pate Service 20 Time of Service 'A.1,1111 e M o o t; /I (ZO07 17 18 21. A PT M Tim Miles Date Time Miles Int. ate Time Miles Int. Date Time Miles Int. Date Time Miles Int. Date Time Miles Int ,- ,,, r • A sPY l.:ti ] rt ?rv-..,, '. .a i.,.. tl .y,.;1?-?4id ?'.^biru?e a.. wMw.w......:_ IPTNxtl. ? ?:. ..:,?wP?? ILL ?vyW?+4+?Fb? .,..... ........ X? '} *: H! t[ ?yyyy o* 4 ?: F"' rji /'? nF .? ?? ?i; ?? ?. 3 OF 3 COUNTY OF'YORK OFFICE OF THE SHERIFF SER)1?;961 45 N. GEORGE ST., YORK, PA 17401 SHERIFF SERVICE WSTRMTH)INS PROCESS RECEIPT and AFFIDAVIT OF RETURN PLEASE TYPE ONLY LINE 1 THRU 12 DO NOT DETACH ANY COPES 1 PLAINTIFF/S/ 2 COURT NUMBER Washington National Insurance Company 07-6648 civil 4. TYPE OF WRIT OR COMPLAINT 3. DEFENDANT/S/ Barry Beinhower et al Complaint A N D N O T I C E SERVE 5. NAME OF INDIVIDUAL. COMPANY. CORPORATION, ETC TO SERVE OR DESCRIPTION OF PROPERTY TO BE LEVIED, ATTACHED, OR SOLD Courtney Myers 6. ADDRESS (STREET OR RFO WITH BOX NUMBER, APT. NO.. CITY, BORO, TWP .STATE AND ZIP CODE) AT 555 Hillcrest Road, York, PA 17403 7. INDICAA SERVICE: XIS PERSONAL U PERSON IN CHARGE XXDEPUTIZE .1 CERT. FAIL , U 1ST CLASS MAIL U POSTED U OTHER NOW November 8 , 20 07 I, SHERIFF OF >G'? OUNTY, PA, do hereby deputize the sheriff of York COUNTY to execute this W return them rding to law. This deputization being made at the request and risk of the plaintiff., .- SHERIFF OF11110AW 8. SPECIAL INSTRUCTIONS OR OTHER INFORMATION THAT WILL ASSIST IN EXPEDITING SER66'T 0 F C 0 U N T Y Cumberland Please mail return of service to Cumberland County Sheriff. Thank you. ADV FEE PAID BY ATTY. NOTE: ONLY APPLICABLE ON WRIT OF EXECUTION: N.B. WAIVER OF WATCHMAN - Any deputy sheriff levying upon or attaching any property under within writ may leave same without a watchman, in custody of whomever is found in possession, after notifying person of levy or a ment, without liability on the part of such deputy or the sheriff to any plaintiff herein for any loss, destruction, or removal of any property before sheriffs sale thereo . j 1911 9. TYPE NAME and ADDRESS of ATTORNEY / ORIGINATOR and SIGNATURE 10. TELEPHONE NUMBER 11 DATE FILED Douglas P. France, 2675 Eastern Boulevard, YO PA 17402 757-4565 11-1-2007 12. SEND NOTICE OF SERVICE COPY TO NAME AND ADDRESS BELOW: (This area must be completed if notice is to be mailed). Douglas P. France, Esquire, 2675 Eastern Boulevard, York, PA 17402 CUMBERLAND CO S H E R I F F SPACE BELOW FOR USE OF THE SHERIFF - DO NOT WRITE BELOW THIS LINE 13. 1 acknowledge receipt of the writ 14. DATE RECEIVED 15. Expiration/Hearing Date or complaint as indicated above. M J M C G I L L Y C S O 111-13-2007 112-1-2007 16. HOW SERVED: PERSONAL *.,j RESIDENCE ( ) POSTED( ) POE ( ) SHERIFF'S OFFICE OTHER ( ) SEE REMARKS BELOW 17. O 1 hereby cejOlif-inq return a NOT FOUND because I am unable to locate the individual, company, etc. named above. (See remarks below.) 18. E AND TLE F NDIV L ED / LIST ADDRE S HERE IF NOT w WN ABOVE (Relationship to Defendant) 19. Ole of ervice 20 Time of Service fE mfle- : X? yes II W /07 17.1 21. ATTEMPTS Da ime Miles I Date a Miles Int. Date Time Miles Int. Date Time Miles Int. Date Time Miks Int. Date Time Miles Int. rr zrz D DPI 22. REMARKS: I ? l I ?2 d I 23. Advance Costs 24 Service Costs 25 N/F 26. Mileage 27. P 28. Sub Total 29. Pound 30. Notary 31. Surchg. 32. Tot. Costs 33 Costs Due or Refund r eck No 34. Foreign County Costs 35. Advance Costs 36. Service Costs 37Notary Cert. 38. )t Found 39. Total Costs 40. Costs Due or Refund 41 AFFIRMS ANSWERS . PI 44 Si f t / 42 d . gna ure o /A r ( gSXT x . 3g ay CSTA?t m Dep. Sheriff O - 7 V / OTAR NOTARY U L{ . MR BOWMAN LISA L 46. Signature of York _ a7 DATE , . CITY OF YORK YORK COUNTY MY COMMISSION EXPIRES AUG. 12,2M County Sheriff WILLIAM M H O S E , S H E R I F F 2 - 6 - 2 0 0 7 48. Signature of Foreign 49 DATE County Sheriff Vn..vv.L-V mizl tz- 1 ur 1 nC JnCRlrr a RC 1 ur%im onar%A 1 umt 51. DA It RECEIVED OF AUTHORIZED ISSUING AUTHORITY AND TITLE 1. WHITE - Issuing Authority 2. PINK - Attorney 3. CANARY - Sheriffs Office 4. BLUE - Shenfrs Office _. r 1i +?.y }s•.[?- S? U f S Lo ?-- V ? 1'?_ 1 3 ? - ? - .. _.... - ? C ` ,. t k+ . L +r a IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA WASHINGTON NATIONAL INSURANCE COMPANY, Plaintiff, V. BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower, Defendants. CIVIL ACTION- EQUITY CASE NO. 07-6648 PRAECIPE TO THE PROTHONOTARY: Please reinstate the Complaint which was originally filed of record on November 1, 2007 and Reinstated November 30, 2007 Respectfully Submitted: KAGEN, MACDON LD & FRANCE, P.C. Douglas ance, Esquire Attorney ID No. 48744 2675 Eastern Boulevard York, PA 17402-2905 Phone: (717) 757 - 4565 Date April 14, 2008 I "%r IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA WASHINGTON NATIONAL INSURANCE COMPANY, CIVIL ACTION- EQUITY Plaintiff, V. CASE NO. 07-6648 BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower, Defendants. CERTIFICATE OF SERVICE AND NOW, to wit, this I<tL day of April, 2008, I, Douglas P. France, Esquire, do hereby certify that I have this date served a copy of the foregoing Praecipe to Reinstate Complaint by depositing same in the United States Mail, First Class mail, postage prepaid, addressed to counsel of record as follows: Stephen K. Portko, Esquire Bratic & Portko 101 South U.S. Route 15 Dillsburg, PA 17079 Jacqueline M. Welby, Esquire Skarlatos & Zonarich Skarlatos & Zonarich Building 17S2 n1 Street, 6th Floor Harrisburg, PA 17101 KAGEN, MacDONALD & FRANCE, P.C. By: Douglas . r ce, Esquire 2675 Easter oulevard York, Pennsylvania 17402 I.D. #48744 spa C71 ? ,b ? ' , 00 a SHERIFF'S RETURN - REGULAR CASE NO: 2007-06648 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND WASHINGTON NATIONAL INSURANCE VS BEINHOWER BARRY ET AL MICHAEL BARRICK , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon BEINHOWER NANCY the DEFENDANT , at 1613:00 HOURS, on the 28th day of April , 2008 at 4831 E TRINDLE ROAD MECHANICSBURG, PA 17055 NANCY BEINHOWER by handing to a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Additional Comments DEFENDANT HAS DEMENTIA AND WAS SERVED WITH SAFA BALTIC, / MEADOWS COORDINATOR AND HENRI LIVELY, CAMPUS EXECUTIVE DIRECTOR AS WITNESSES TO THE SERVICE OF THE COMPLAINT. Sheriff's Costs: Docketing 18.00 Service 12.00 Postage .58 Surcharge 10.00 .00 .4"/6 n/cf/ ? 4 0. 5 8 Sworn and Subscibed to before me this day So Answers: R. Thomas Kline 04/30/2008 KAGEN MACDONALD By. i j eputy Sheriff of A. D. . Archer & Archer, P.C. By: Thomas A. Archer, Esquire 2515 North Front Street P.O. Box 5056 Harrisburg, PA 17110 WASHINGTON NATIONAL INSURANCE COMPANY, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA Plaintiff, V. BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSELL, Executrix of the Estate of Clair Beinhower, Defendants. CIVIL ACTION - EQUITY DOCKET NO.: 07-6648 CIVIL TERM PRAECIPE FOR WITHDRAWAL-SUBSTITUTION OF APPEARANCE TO THE PROTHONOTARY: WITHDRAWAL OF APPEARANCE Kindly substitute my appearance on behalf of the Plaintiff in the above-captioned matter with the undersigned counsel, Thomas A. Archer, Esquire KAGEN, MACDONALD & FRANCE, P.C. Date: v Ug By: Dou 1 s P. France, Esquire ENTRY OF APPEARANCE Kindly enter my appearance on behalf of the Plaintiff in the above-captioned matter in place of Douglas P. France, Esquire. ?RCHER & ARCHER, P.C. Date: .r-,? as `?-. By: Thomas A. Archer, Esquire w CERTIFICATE OF SERVICE I, Thomas A. Archer, Esquire, hereby certify that on the date set forth below I served a true and correct copy of the foregoing Praecipe for Withdrawal-Substitution of Appearance upon the person(s) stated below, via U.S. Mail, postage prepaid, addressed as follows: Jacqueline Welby, Esquire Skarlatus & Zonarich, LLP 17 South Second Street, 6th Floor Harrisburg, PA 17101 Attorney for Terri Cassel and Nancy Beinhower Stephen K. Portko, Esquire Bratic & Portko 101 South U.S. Route 15 Dillsburg, PA 17019 Attorney for Barry Beinhoiver, Nancy KogondcZ and Courtney Myers Date: May 5, 2008 Thomas A. Archer, Esquire Attorney I.D. # 73293 Attorney for Plaintiff ". ?t -.?C 't3 ?v J ? r u A Archer & Archer, P.C. By: Thomas A. Archer, Esquire 2515 North Front Street P.O. Box 5056 Harrisburg, PA 17110 tarchera,archerandarcher. com Attorney for Plaintiff, Washington National Insurance Company WASHINGTON NATIONAL INSURANCE COMPANY, Plaintiff, v. -BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSELL, Executrix of the Estate of Clair Beinhower, Defendants. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY : PENNSYLVANIA : CIVIL ACTION - EQUITY DOCKET NO.: 07-6648 CIVIL TERM PLAINTIFF'S REPLY TO NEW MATTER OF DEFENDANTS, BARRY BEINHOWER, NANCY ROGOWICZ and COURTNEY MYERS AND NOW, Plaintiff, Washington National Insurance Company ("WNIC"), by and through it's undersigned counsel, Thomas A. Archer, Esquire, replies to Defendants' New Matter as follows: 24. Plaintiff hereby incorporates the allegations contained in its Complaint for Equitable Interpleader as though fully set forth herein at length. 25. After reasonable investigation, Plaintiff is without sufficient information to determine the accuracy of the averments of this paragraph which, are accordingly denied. The allegations of this paragraph are also denied to the extent they constitute conclusions of law to which no response is required. By way of further response, Rocca Capunno, Jr. CEP, RFC, was acting as agent for Clair Beinhower and not WNIC. 26. After reasonable investigation, Plaintiff is without sufficient information to determine the accuracy of the averments of this paragraph which, are accordingly denied. The allegations of this paragraph are also denied to the extent they constitute conclusions of law to which no response is required. By way of further response, Rocca Capunno, Jr. CEP, RFC, was acting as agent for Clair Beinhower and not WNIC. 27. Admitted in part; denied in part. It is admitted only that MNIC received a Customer Service Form purporting to change the identity of the named beneficiaries. After reasonable investigation, Plaintiff is without sufficient information to determine the accuracy of the remaining averments of this paragraph which, are accordingly denied. The allegations of this paragraph are also denied to the extent they constitute conclusions of law to which no response is required. By way of further response, Rocco Capunno, Jr. CEP, RFC, was acting as agent for Clair Beinhower and not WNIC. 28. Admitted in part; denied in part. It is admitted that WNIC caused the issuance of annuity proceeds to Barry Beinhower and admitted that WNIC caused the stop payment of its check after receiving additional claims for the same policy in the interim. The remaining allegations of this paragraph are denied as conclusions of law to which no response is required. 29. Denied as a conclusions of law to which no response is required. By way of further response, Defendants' New Matter does not identify the agent whom it is alleged stated that any claim by Terri Cassel on behalf of Nancy Beinhower had been rejected. Accordingly, to the extent this is an allegation of fact, it is denied. By way of further response, Rocco Capuano, Jr. CEP, RFC was acting as agent on behalf of Clair Beinhower and not WNIC. 2 30. Denied as a conclusion of law to which no response is required. WHEREFORE, Plaintiff, Washington National Insurance Company, respectfully requests the relief sought in its Complaint for Equitable Interpleader. Respectfully submitted, ARCHER & MARCHER, P.C. Date: May 7, 2008 By: 1/? Thomas A. Archer, Esquire PA Atty ID No.: 73293 2515 North Front Street PO Box 5056 Harrisburg, PA 17110 717-233-8676 3 CERTIFICATE OF SERVICE I, Thomas A. Archer, Esquire, hereby certify that on the date set forth below I served a true and correct copy of the foregoing Reply to New Matter upon the person(s) stated below, via U.S. Mail, postage prepaid, addressed as follows: Jacqueline Welby, Esquire Skarlatus & Zonarich, LLP 17 South Second Street, 6th Floor Harrisburg, PA 17101 Adorn y for Tern Cassel and Nancy Beinhmver Stephen K. Portko, Esquire Bratic & Portko 101 South U.S. Route 15 Dillsburg, PA 17019 Allorn y for Barry Beinhower, Nancy Rogou,,cZ and Courtn y Myers Date: May 7, 2008 e 4#04 - Thomas A. Archer, Esquire Attorney I.D. # 73293 Attorney for Plaintiff {"') w Q 66 ? co cu >- U3 A iV IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA WASHINGTON NATIONAL INSURANCE COMPANY, CIVIL ACTION - EQUITY Plaintiff, V. CASE NO. 07-6648 CIVIL TERM BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower, Defendants. MOTION FOR CONSOLIDATION AND NOW, this 18th day of June, 2008, Defendant, Terri Cassel, Executrix of the Estate of Clair Beinhower (hereinafter "Cassel") by and through her counsel, Jacqueline Welby, Esq., of the law office of Skarlatos & Zonarich, LLP, requests that this Honorable Court enter an Order consolidating the above captioned action with another pending action and in support thereof avers as follows: 1. Plaintiff, Washington National Insurance Company, filed a Complaint for Equitable Interpleader on October 31, 2007 against Defendant, Cassel, as Executrix for the Estate of Clair Beinhower, and other parties as listed in the caption, requesting that this Court accept the proceeds of an annuity in the amount of $36,962.46, to be deposited with the Court and to hear the adverse claims of Defendants, as the Defendants have adverse claims to the proceeds. 2. In another action pending before this Court, Lincoln Financial Group filed a Complaint for Equitable Interpleader on April 18, 2008, 08-2526 Civil Term, against the identical Defendants, requesting that Lincoln be permitted to deposit an annuity in the amount of $16,650.00 proceeds and hear the adverse claims of the Defendants to the annuity proceeds. 3. The above-captioned matters involve common questions of both law and fact, and much, if not all, of the discovery and evidence presented in connection with one of the cases will be equally applicable to the discovery and hearing of the other action. 4. Both interpleader actions involve questions as to the validity of the change of beneficiary designations on the annuities issued by the Plaintiff insurance companies by the agent under the Power of Attorney of decedent Clair Beinhower. 5. Washington National Insurance Company, Lincoln Financial Group, and the Defendants to both actions, through their individual counsel, consent to this motion. 6. This Honorable Court has not ruled on any matter in either of the actions in which consolidation is requested. WHEREFORE, Defendant Terri Cassel, Executrix of the Estate of Clair Beinhower, respectfully requests that this Honorable Court order these actions consolidated. Skarlatos & Zonarich, LLP Dated: G-4 y By: _ -91 Appreme elin . Welby, Esquire Ct. I.D. # 57672 . Second Street, 61h Floor Harrisburg, PA 17101 (717) 233-1000 Attorney for Defendant 0 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA WASHINGTON NATIONAL INSURANCE COMPANY, CIVIL ACTION - EQUITY Plaintiff, TERM V. CASE NO. 07-6648 CIVIL BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower, Defendants. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA LINCOLN NATIONAL LIFE INSURANCE COMPANY, d/b/a LINCOLN FINANCIAL GROUP Plaintiff, TERM V. CIVIL ACTION - EQUITY CASE NO. 08-2526 CIVIL BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower, Defendants. VERIFICATION I, Jacqueline Welby, Esq., attorney for Defendant Terri Cassel, Executrix of the Estate of Clair Beinhower, verify that I have read the foregoing document and that the facts set forth therein are true and correct to the best of my knowledge, information and belief; and that this verification is subject to the penalties of 18 Pa. Cons. Stat. § 4904 related to unsworn falsification to authorities. Dated: - V J ine elby IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA WASHINGTON NATIONAL INSURANCE COMPANY, Plaintiff, V. BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower, Defendants. CIVIL ACTION - EQUITY CASE NO. 07-6648 CIVIL TERM IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA LINCOLN NATIONAL LIFE INSURANCE COMPANY, d/b/a LINCOLN FINANCIAL GROUP Plaintiff, V. BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower, Defendants. CIVIL ACTION - EQUITY CASE NO. 08-2526 CIVIL TERM CERTIFICATE OF SERVICE I, Jacqueline Welby, Esquire, an attorney with the law firm of Skarlatos & Zonarich, LLP, hereby certify that I this day served a copy of the foregoing document upon the person(s) indicated below by depositing a copy of the same in the United States Mail, postage prepaid, at Harrisburg, Pennsylvania, and addressed as follows: Stephen Portko, Esq. Bratic & Portko 101 S. U.S. Route 15 Dillsburg, PA 17019 Nicole L. Bordo, Esq. Thomas Archer, Esq. Buchanan Ingersoll & Rooney, PC Archer & Archer, P.C. 213 Market St., 3rd Flr 2515 N. Front St. Harrisburg, PA 17101 Harrisburg, PA 17110 Dated: G -/s v e ax6d ??? - a uelin elby d te3 r I , 1 u( 9 I JUN 2 0 2008 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA WASHINGTON NATIONAL INSURANCE COMPANY, CIVIL ACTION - EQUITY Plaintiff, V. BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower, Defendants. CASE NO. 07-6648 CIVIL TERM/ IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA LINCOLN NATIONAL LIFE INSURANCE COMPANY, CIVIL ACTION - EQUITY d/b/a LINCOLN FINANCIAL GROUP Plaintiff, V. BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower, Defendants. ORDER CASE NO. 08-2526 CIVIL TERM AND NOW, this Zy` day of ei. : , 2008, upon Motion of Defendant, Terri Cassel, Executrix of the Estate of Clair Beinhower, it.is ordered that the above captioned actions are consolidated for purposes of discovery and trial. Notice shall be provided to the following persons: Stephen Portko, Esq., Bratic & Portko, 101 S. U.S. Route 15, Dillsburg, PA 17019 Nicole L. Bordo, Esq., Buchanan Ingersoll & Rooney, PC, 213 Market St., 3`d Flr, Harrisburg, PA 17101 Thomas Archer, Esq., Archer & Archer, P.C., 2515 N. Front St., Harrisburg, PA 17110 Jacqueline Welby, Esq., Skarlatos & Zonarich, LLP, 17 S. Second St., 6`h Flr, Harrisburg, PA 17101 By the Court: orll-l .N cm-lwld ?Jrc? . ?tv i-tttl s H}tl r Atttd s-41JO • 1? V 60 :g 11V SZ I'M 8092 , t3ol 's -C/07 Atlitl J ,i :: 1 v Eli i dG Bratic & Portko Stephen K. Portko, Esquire 101 South U.S. Route 15 Dillsburg, PA 17019 Tel: (717) 432-9706 Fax: (717) 432-9220 Email: braticportko@aol.com Attorneys for Defendants, Barry Beinhower, Nancy Rogowicz and Courtney Myers, a Minor Child IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA WASHINGTON NATIONAL INSURANCE COMPANY, Plaintiff, CIVIL ACTION - EQUITY V. BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower, Defendants. CASE NO. 07-6648 CIVIL TERM IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA LINCOLN NATIONAL LIFE INSURANCE COMPANY, d/b/a LINCOLN FINANCIAL GROUP Plaintiff, CIVIL ACTION - EQUITY V. BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower, Defendants. CASE NO. 08-2526 CIVIL TERM PETITION FOR APPROVAL OF MINOR'S SETTLEMENT TO THE HONORABLE, THE JUDGES OF THE SAID COURT: Pursuant to Pa. R.C.P. No. 2039, Nancy Rogowicz, the parent and natural guardian of minor Courtney Myers, by and through her attorneys, Bratic & Portko, petitions this Court to enter an order permitting settlement in compromise of these actions, and in support avers the following: BACKGROUND 1. Nancy Rogowicz is the parent and natural guardian of minor, Courtney Myers, who was born on November 24, 2001, and who is presently 7 years of age. 2. Courtney Myers, the minor, beneficiary designee resides with her mother and natural guardian at 555 Hillcrest Road, York, York County, Pennsylvania. HISTORY OF CONTROVERSARY 3. On March 17, 2007, Clair Beinhower, (the "Decedent") died, a resident of Cumberland County, Pennsylvania. 4. At the time of Decedent's death, there was in existence a deferred annuity, policy no. EN5328266 (Annuity) issued by Lincoln Financial Group, successor to Jefferson -Pilot Life Insurance Company to Clair Beinhower, Decedent (Annuitant). The annuity proceeds with accrued interest are approximately $16,650.00. 5. There was also in existence at the time of Decedent's death a flexible premium deferred index annuity issued Washington National Insurance Company (to Annuitant). The annuity proceeds with accrued interest approximately $39,962.46. 6. After the death of the annuitant, a dispute arose between Barry Beinhower, Nancy Rogowicz, Courtney Myers, Nancy Beinhower, and Terri Cassel, Executrix of the Estate of Clair Beinhower over the proper beneficiaries of the two (2) policies. 7. Subsequently, Plaintiff Washington National Insurance Company filed a Complaint for Equitable Interpleader on October 31, 2007 (Equity Case No. 07-6648 Civil Term) against Defendant Cassel, as Executrix for the Estate of Clair Beinhower, and other parties as listed in the caption requesting that this Court accept the proceeds of an annuity in the amount of $36,962.46, to be deposited with the Court and to hear the adverse claims of Defendants, as the Defendants have adverse claims to the proceeds. In another action pending before this Court, Lincoln Financial Group also filed a Complaint for Equitable Interpleader on April 18, 2008, (EQUITY Case No. 08-2526 Civil Term) against the identical Defendants, requesting that Lincoln be permitted to deposit with the court their annuity proceeds in the amount of $16,650.00 and hear the adverse claims of Defendants to the annuity proceeds. 9. Both interpleader actions involved questions as to the validity to the change of beneficiary designations on the annuities issued by the insurance companies at the request of an agent (Barry Beinhower) under the Power of Attorney of Decedent, Clair Beinhower. 10. Terri Cassel, Executrix of the Estate of Clair Beinhower and Nancy Beinhower, through their attorney, Skarlatos & Zonarich LLP, and Defendants Barry Beinhower, Nancy Rogowicz, and Courtney Myers, a Minor, through their attorney, Bratic and Portko, have reached an agreement regarding the distribution of the insurance proceeds. 11. The following agreements to settle have been proposed: A. WASHINGTON NATIONAL INSURANCE COMPANY In accordance with a proposed Settlement Agreement and Release attached hereto and marked Exhibit A. In summary the proceeds of the annuity, policy number VAR002347, issued by Plaintiff, Washington National Insurance Company ("WNIC") be divided amongst the Defendants as follows: 50% payable to Nancy Beinhower 50% payable to Barry Beinhower, Nancy Rogowicz, and Courtney Meyers to be allocated in equal shares. The amount payable to Courtney Meyers, a minor child, is to be held in an interest bearing account until she turns eighteen (18) years of age. B. LINCOLN NATIONAL LIFE INSURANCE COMPANY In accordance with a proposed Settlement Agreement and Release attached hereto and marked Exhibit B. In summary the proceeds of the annuity, policy number EN5328266, issued by Plaintiff, Lincoln National Life Insurance Company, d/b/a Lincoln Financial Group ("LFG") be divided amongst the Defendants as follows: 50% payable to Nancy Beinhower 50% payable to Barry Beinhower, Nancy Rogowicz, and Courtney Meyers to be allocated in equal shares. The amount payable to Courtney Meyers, a minor child, is to be held in an interest bearing account until she turns eighteen (18) years of age. 12. The Petitioner and counsel seek approval of the total settlement on behalf of the Minor, Courtney Myers, in accordance with the distribution outlined in paragraph 11, (A) & (B) the amount of $ because they believe it represents a full and fair settlement of the case equal to or greater than that which may be obtained should the matter be fully litigated. 13. Counsel for Petitioner is of the professional opinion that due to the uncertainties of litigation, the proposed compromise is reasonable and is in the best interest of the minor, plaintiff, Courtney Myers. 14. Petitioner, Nancy Rogowicz, the parent and natural guardian of minor, Courtney Myers, concurs in the proposed settlement and distribution. 15. Nancy Beinhower and Terri Cassel, Executrix of the Estate of Clair Beinhower, by and through their attorneys, John R. Zonarich, Esquire of Skarlatos & Zonarich LLP join in this petition and concur in the settlement and compromise of these actions. 16. Petitioners, further approve the proposed distribution contained in the form Order attached. 17. No hearing is requested. WHEREFORE, Petitioner, Nancy Rogowicz, the parent and natural guardian of Courtney Myers, requests that this Court enter an Order approving the proposed Settlement and Compromise, authorize Petitioner to make distribution pursuant to the Petition, to execute all necessary releases and endorse all checks. Respectfully submitted, Dated: January z"; 2009 BY:? Stephtn K. Portko, Esq. Bratic & Portko 101 South U.S. Route 15 Dillsburg, PA 17019 Tel: (717) 432-9706 Fax: (717) 432-9220 Email: braticportkoaaol.com VERIFICATION I, Nancy Rogowicz, hereby certifies that the facts set forth in the following Petition are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language in the Petition is that of counsel and not my own. I have read the Petition, and to the extent it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information and belief. To the extent that the content of the Petition is that of counsel, I have relied upon counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition are made subject to the penalties of 18 Pa.C.S.A. §4904 relating to unsworn falsification to authorities. Dated: 11,3469 ?IaA&4 t;Q0eI(Mr N c ogo z CERTIFICATE OF SERVICE I, d2G1-- n - fik? , an employee with the law firm of Bratic & Portko, 16 hereby certify that I this day served a copy of the foregoing PETITION FOR APPROVAL OF MINOR'S SETTLEMENT upon the person(s) indicated below by depositing a copy of the same in the United States Mail, postage prepaid, at Harrisburg, Pennsylvania, and addressed as follows: Nancy Rogowicz 555 Hillcrest Road York, PA 17403 John R. Zonarich, Esquire Skarlatos & Zonarich LLP 17 South Second Street, 6 h Fl Harrisburg, PA 17101 Attorneys for Defendants Terri Cassel and Nancy Beinhower Thomas A. Archer, Esquire Archer & Archer P.C. 2515 North Front Street P.O. Box 5056 Harrisburg, Pa 17110 Attorney for Plaintiff, Washington National Insurance Company Nicole L. Borda, Esquire Buchanan Ingersoll & Rooney PC 213 Market Street, 3`a Floor Harrisburg, PA 17101 Attorney for Plaintiff Lincoln National Life Insurance Company Date: January ?'?, 2009 CERTIFICATION OF PARENTS AND NATURAL GUARDIANS I, Nancy Rogowicz, hereby certify that I am the parent and natural guardian of the minor, Courtney Myers, who is presently seven (7) years of age. I have reviewed and discussed with counsel the proposed settlement and distribution as set forth in the foregoing petition including the proposed order and schedule of distribution. I have signed this certification, concur with and join in this petition and I recommend that the court approve this settlement and distribution schedule. I understand that this certification is made pursuant to provision 18 Pa. Cons. Stat. § 4904, relating to untold falsification to authority. Dated: [ I f 3-40 C' EXHIBIT "A" Archer & Archer, P.C. By: Thomas A. Archer, Esquire 2515 North Front Street P.O. Box 5056 Harrisburg, PA 17110 tarchern,archerandarcher.com Attorney for Plaintiff, Washington National Insurance Company WASHINGTON NATIONAL : IN THE COURT OF COMMON PLEAS INSURANCE COMPANY, : OF CUMBERLAND COUNTY PENNSYLVANIA Plaintiff, V. CIVIL ACTION - EQUITY BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI : DOCKET NO.: 07-6648 CIVIL TERM CASSELL, Executrix of the Estate of Clair Beinhower, Defendants. SETTLEMENT AGREEMENT AND RELEASE This SETTLEMENT AGREEMENT AND RELEASE ("Agreement") is made this day of January, 2009, between and among Plaintiff, Washington National Insurance Company ("WNIC") and Defendants, Barry Beinhower, Nancy Rogowicz, Courtney Myers through her parent and natural guardian, Nancy Rogowicz, Nancy Beinhower and Terri Cassel, Executrix of the Estate of Clair Beinhower. WHEREAS, there was in existence a flexible premium deferred index annuity, policy number VAR002347 ("Annuity") issued by WNIC to Clair Beinhower ("Annuitant"). WHEREAS, the Annuity provided a death benefit of $36,585.85 payable upon the death of the Annuitant ("Annuity Proceeds"). WHEREAS, Defendant, Nancy Beinhower has made a claim to WNIC for the Annuity Proceeds and Defendants, Barry Beinhower, Nancy Rogowicz and Courtney Myers have made a separate claim to WNIC for the Annuity Proceeds. WHEREAS, WNIC filed it's Complaint for Equitable Interpleader in the above- captioned action on or about November 1, 2007, requesting a Court Order, among other things, decreeing that the value of the Annuity Proceeds, $39,962.46, be tendered to the Court, that WNIC be discharged from all liability to the relative claims and ordering the Defendants to appear and present their claims to the Annuity Proceeds. WHEREAS, each of the Defendants has filed an Answer to the Complaint for Equitable Interpleader, seeking to perfect the claim of each to the Annuity Proceeds. WHEREAS, the Defendants have conferred and agreed that it is in their mutual best interest to forego continued litigation and have agreed to resolve and settle the claims which have been raised or could have been raised among the parties concerning the Annuity and Annuity Proceeds. NOW THEREFORE, in consideration of the mutual covenants contained in this Agreement, and it being the intention of the parties to be legally bound, the parties to this Agreement settle and completely resolve the claims among them as follows: 1. Recitals. The parties hereby incorporate all of the recitals listed above as if set forth at length herein. 2. Settlement Terms. The Annuity Proceeds are $39,962.46. WNIC shall cause one-half of the Annuity Proceeds ($19,981.23) to be issued to the order of Defendant, Nancy Beinhower and shall cause one-half of the Annuity Proceeds ($19,981.23) to be issued to the order of Defendants, Barry 2 Beinhower, Nancy Rogowicz and Courtney Myers, payable to Nancy Rogowicz as trustee on behalf of Courtney Myers, in equal 1/3 shares as nearly as can be calculated. Payment shall be delivered to Defendants' respective counsel within thirty (30) days of the execution of this Settlement Agreement and Release by all Parties and any necessary approval of minor's settlement by the Court. 3. Mutual Release. In exchange for the consideration described in Paragraph 2 herein, the parties agree to fully and forever release each other, including each of their respective officers and directors, subsidiaries, divisions, affiliates, principals, predecessors, successors, assigns, licensees, related companies or entities, heirs and each of their respective present or former officers, directors, employees, shareholders, investors, accountants, owners, trustees, attorneys, agents, and representatives, from any and all liabilities, obligations, claims, actions, causes of action and demands of any type or nature whatsoever, known or unknown, suspected or unsuspected which against each other the parties ever had, now have or hereafter can or shall or may have, arising out of or related in any way to the Defendants claims to the Annuity Proceeds. 4. Dismissal of Action. Upon payment of all sums set forth in Paragraph 2 herein, Plaintiff shall cause the above-captioned action to be dismissed with prejudice. 5. Benefit and No Assignment. Except as otherwise expressly provided, this Settlement Agreement and Release shall inure to the benefit of and be binding upon the parties and their respective heirs, successors and executors. The 3 parties represent and warrant that they have not assigned or in any other manner conveyed any right or claim that they have or may have to any third party, and the parties shall not assign or convey to any assignee for any reason any right or claim covered by this Agreement, or the consideration, monetary or other, to be received hereunder. 6. Full, Final and Binding Agreement. This Agreement represents the full, final integrated agreement of the parties hereto as to the subject matter hereof. This Agreement may only be modified or amended by a further writing executed by the parties hereto. 7. No Admissions. The consideration provided for herein is being exchanged solely to amicably resolve the litigation of disputed claims and neither the exchange of such consideration, nor anything contained herein, shall be taken or construed to be at any time or place an admission on the part of any party hereto of any of the claims alleged or amounts claimed between such parties, and they expressly deny any such claims or amounts claimed. 8. Annlicable Law. The parties hereto enter into this Release and Settlement Agreement in the Commonwealth of Pennsylvania, and said document shall be construed and interpreted in accordance with its laws. 9. Severability. Should any part of this Agreement be adjudged unenforceable by a court of competent jurisdiction, the remaining provisions of this Agreement shall remain in full force and effect. 10. Counterparts. This Agreement may be signed an enforced in counterparts and enforced by facsimile signatures. 4 The parties, intending to be legally bound by the terms of this Release and Settlement Agreement hereunto, set their hand and seal on the first date set forth above. ATTEST: WNIC: By: By: Terri Cassel, Executrix of the Estate of Clair Beinhower By: Nancy Beinhower By: Barry Beinhower By: Nancy Rogowicz By: Courtney Myers through her parent and natural guardian, Nancy Rogowicz 5 EXHIBIT "B" IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA LINCOLN NATIONAL LIFE INSURANCE COMPANY, d/b/a LINCOLN FINANCIAL GROUP Plaintiff CIVIL ACTION-EQUITY V. BARRY BEINHOWER, NANCY ROGOWICZ, COURTNY MYERS, NANCY BEINHOWER, and TERRI CASSEL, as Executrix of the Estate of Clair Beinhower, Defendants CASE NO. 08-2526 SETTLEMENT AGREEMENT AND RELEASE This SETTLEMENT AGREEMENT AND RELEASE ("Agreement") is made this day of , 2008, between and among Plaintiff, Lincoln National Life Insurance Company, d/b/a Lincoln Financial Group ("Lincoln") and Defendants, Barry Beinhower, Nancy Rogowicz, Courtney Myers, through her parent and natural guardian, Nancy Rogowicz, Nancy Beinhower, and Terri Cassel, Executrix of the Estate of Clair Beinhower. WHEREAS, there was in existence a deferred annuity, policy number EN532826 ("Annuity") issued by Jefferson Pilot Life Insurance Company to Clair Beinhower ("Annuitant") WHEREAS, the Annuity provided a death benefit of $ upon the death of the Annuitant ("Annuity Proceeds"). payable WHEREAS, Defendant Nancy Beinhower has made a claim to Lincoln for the Annuity Proceeds and Defendants, Barry Beinhower, Nancy Rogowicz and Courtney Myers have made a separate claim to Lincoln for the Annuity Proceeds. WHEREAS, Lincoln filed its Complaint for Equitable Interpleader in the above- captioned action on or about April 18, 2008, requesting a Court Order, among other things, decreeing that the value of the Annuity Proceeds be tendered to the Court, that Lincoln be discharged from all liability to the relative claims and ordering the Defendants to appear and present their claims to the Annuity Proceeds. WHEREAS, the Defendants have conferred and agreed that it is in their mutual best interest to forego continued litigation and have agreed to resolve and settle the claims that have been raised or could have been raised among the parties concerning the Annuity and Annuity Proceeds. NOW THEREFORE, in consideration of the mutual covenants contained in this Agreement, and it being the intention of the parties to be legally bound, the parties to this Agreement settle and completely resolve the claims among them as follows: 1. Recitals. The parties hereby incorporate all of the recitals listed above as if set forth at length herein. 2. Settlement Terms. The Annuity Proceeds are $16,650.00. Lincoln shall cause one-half of the Annuity Proceeds ($8,325.00) to be issued to the order of Defendant, Nancy Beinhower and shall cause one-half of the Annuity Proceeds ($8,325.00) to be issued to the order of Defendants, Barry Beinhower, Nancy Rogowicz, and Courtney Myers, made payable to Nancy Rogowicz as trustee on behalf of Courtney Meyers, in equal 1/3 shares as nearly as can be calculated. Payment shall be delivered to Defendants' respective counsel within thirty (30) days of the execution of this Settlement Agreement and Release by all Parties and 2 any necessary approval by the Court of the minor's settlement on behalf of Courtney Meyers. 3. Mutual Release. In exchange for the consideration described in Paragraph 2 herein, the parties agree to fully and forever release each other, including each of their respective officers and directors, subsidiaries, divisions, affiliates, principals, predecessors, successors, assigns, licensees, related companies or entities, heirs and each of their respective present or former officers, directors, employees, shareholders, investors, accountants, owners, trustees, attorneys, agents, and representatives, from any and all liabilities, obligations, claims, actions, causes of action and demands of any type or nature whatsoever, known or unknown, suspected or unsuspected which against each other the parties ever had, now have or hereafter can or shall or may have, arising out of or related in any way to the Defendants' claims to the Annuity Proceeds. 4. Dismissal of Action. Upon payment of all sums set forth in Paragraph 2 herein, Plaintiff shall cause the above-captioned action to be dismissed with prejudice. 5. Benefit and No Assignment. Except as otherwise expressly provided, this Settlement Agreement and Release shall inure to the benefit of and be binding upon the parties and their respective heirs, successors and executors. The parties represent and warrant that they have not assigned or in any other manner conveyed any right or claim that they have or may have to any third party, and the parties shall not assign or convey to any assignee for any reason any right 3 or claim covered by this Agreement, or the consideration, monetary or other, to be received hereunder. 6. Full Final and Binding Agreement. This Agreement represents the full, final integrated agreement of the parties hereto as to the subject matter hereof. This Agreement may only be modified or amended by a further writing executed by the parties hereto. 7. No Admissions. The consideration provided for herein is being exchanged solely to amicably resolve the litigation of disputed claims and neither the exchange of such consideration, nor anything contained herein, shall be taken or construed to be at any time or place an admission on the part of any party hereto of any of the claims alleged or amounts claimed between such parties, and they expressly deny any such claims or amounts claimed. 8. Anylicable Law. The parties hereto enter into this Release and Settlement Agreement in the Commonwealth of Pennsylvania, and said document shall be construed and interpreted in accordance with its laws. 9. Severability. Should any part of this Agreement be adjudged unenforceable by a court of competent jurisdiction, the remaining provisions of this Agreement shall remain in full force and effect. 10. Counterparts. This Agreement may be signed and enforced in counterparts and enforced by facsimile signatures. 4 The parties, intending to be legally bound by the terms of this Release and Settlement Agreement hereunto, set their hand and seal on the first date set forth above. ATTEST: LINCOLN NATIONAL LIFE INSURANCE COMPANY By: By: Terri Cassel, Executrix of the Estate of Clair Beinhower By: Nancy Beinhower By: Barry Beinhower By: Nancy Rogowicz By: Courtney Meyers, through her parent and natural guardian, Nancy Rogowicz 5 {-r , ,'?' ?? `- »? .. ,?? --. W . ? +.se?r Bratic & Portko Stephen K. Portko, Esquire 101 South U.S. Route 15 Dillsburg, PA 17019 Tel: (717) 432-9706 Fax: (717) 432-9220 Email: braticportko@aol.com Attorneys for Defendants, Barry Beinhower, Nancy Rogowicz and Courtney Myers, a Minor Child IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA WASHINGTON NATIONAL INSURANCE COMPANY, Plaintiff, V. BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower, Defendants. CIVIL ACTION - EQUITY CASE NO. 07-6648 CIVIL TERM ? IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA LINCOLN NATIONAL LIFE INSURANCE COMPANY, d/b/a LINCOLN FINANCIAL GROUP Plaintiff, V. BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower, Defendants. CIVIL ACTION - EQUITY CASE NO. 08-2526 CIVIL TERM AMENDED PETITION FOR APPROVAL OF MINOR'S SETTLEMENT TO THE HONORABLE, THE JUDGES OF THE SAID COURT: Pursuant to Pa. R.C.P. No. 2039, Nancy Rogowicz, the parent and natural guardian of minor Courtney Myers, by and through her attorneys, Bratic & Portko, petitions this Court to enter an order permitting settlement in compromise of these actions, and in support avers the following. The Honorable Kevin A. Hess has entered an order consolidating the cases. BACKGROUND 1. Nancy Rogowicz is the parent and natural guardian of minor, Courtney Myers, who was born on November 24, 2001, and who is presently 7 years of age. 2. Courtney Myers, the minor, beneficiary designee resides with her mother and natural guardian at 555 Hillcrest Road, York, York County, Pennsylvania. HISTORY OF CONTROVERSARY 3. On March 17, 2007, Clair Beinhower, (the "Decedent") died, a resident of Cumberland County, Pennsylvania. 4. At the time of Decedent's death, there was in existence a deferred annuity, policy no. EN5328266 (Annuity) issued by Lincoln Financial Group, successor to Jefferson -Pilot Life Insurance Company to Clair Beinhower, Decedent (Annuitant). The annuity proceeds with accrued interest are approximately $16,650.00. 5. There was also in existence at the time of Decedent's death a flexible premium deferred index annuity issued Washington National Insurance Company (to Annuitant). The annuity proceeds with accrued interest approximately $39,962.46. 6. After the death of the annuitant, a dispute arose between Barry Beinhower, Nancy Rogowicz, Courtney Myers, Nancy Beinhower, and Terri Cassel, Executrix of the Estate of Clair Beinhower over the proper beneficiaries of the two (2) policies. 7. Subsequently, Plaintiff Washington National Insurance Company filed a Complaint for Equitable Interpleader on October 31, 2007 (Equity Case No. 07-6648 Civil Term) against Defendant Cassel, as Executrix for the Estate of Clair Beinhower, and other parties as listed in the caption requesting that this Court accept the proceeds of an annuity in the amount of $36,962.46, to be deposited with the Court and to hear the adverse claims of Defendants, as the Defendants have adverse claims to the proceeds. 8. In another action pending before this Court, Lincoln Financial Group also filed a Complaint for Equitable Interpleader on April 18, 2008, (EQUITY Case No. 08-2526 Civil Term) against the identical Defendants, requesting that Lincoln be permitted to deposit with the court their annuity proceeds in the amount of $16,650.00 and hear the adverse claims of Defendants to the annuity proceeds. 9. Both interpleader actions involved questions as to the validity to the change of beneficiary designations on the annuities issued by the insurance companies at the request of an agent (Barry Beinhower) under the Power of Attorney of Decedent, Clair Beinhower. 10. On June 24, 2008, upon Motion of Defendant Terri Cassel, Executrix of the Estate of Clair Beinhower, the Honorable Kevin A. Hess, entered an Order consolidating both interpleader actions, filed to No. 07-6648 and No. 08-2526, for purposes of discovery and trial. 11. Terri Cassel, Executrix of the Estate of Clair Beinhower and Nancy Beinhower, through their attorney, Skarlatos & Zonarich LLP, and Defendants Barry Beinhower, Nancy Rogowicz, and Courtney Myers, a Minor, through their attorney, Bratic and Portko, have reached an agreement regarding the distribution of the insurance proceeds. 12. The following agreements to settle have been proposed: A. WASHINGTON NATIONAL INSURANCE COMPANY In accordance with a proposed Settlement Agreement and Release attached hereto and marked Exhibit A. In summary the proceeds of the annuity, policy number VAR002347, issued by Plaintiff, Washington National Insurance Company ("WNIC") be divided amongst the Defendants as follows: 50% payable to Nancy Beinhower 50% payable to Barry Beinhower, Nancy Rogowicz, and Courtney Meyers to be allocated in equal shares. The amount payable to Courtney Meyers, a minor child, is to be held in an interest bearing account until she turns eighteen (18) years of age. B. LINCOLN NATIONAL LIFE INSURANCE COMPANY In accordance with a proposed Settlement Agreement and Release attached hereto and marked Exhibit B. In summary the proceeds of the annuity, policy number EN5328266, issued by Plaintiff, Lincoln National Life Insurance Company, d/b/a Lincoln Financial Group ("LFG") be divided amongst the Defendants as follows: 50% payable to Nancy Beinhower 50% payable to Barry Beinhower, Nancy Rogowicz, and Courtney Meyers to be allocated in equal shares. The amount payable to Courtney Meyers, a minor child, is to be held in an interest bearing account until she turns eighteen (18) years of age. 13. The Petitioner and counsel seek approval of the total settlement on behalf of the Minor, Courtney Myers, in accordance with the distribution outlined in paragraph 11, (A) & (B) the amount of $53,612.46 because they believe it represents a full and fair settlement of the case equal to or greater than that which may be obtained should the matter be fully litigated. 14. Counsel for Petitioner is of the professional opinion that due to the uncertainties of litigation, the proposed compromise is reasonable and is in the best interest of the minor, plaintiff, Courtney Myers. 15. Petitioner, Nancy Rogowicz, the parent and natural guardian of minor, Courtney Myers, concurs in the proposed settlement and distribution. 16. Nancy Beinhower and Terri Cassel, Executrix of the Estate of Clair Beinhower, by and through their attorneys, John R. Zonarich, Esquire of Skarlatos & Zonarich LLP join in this petition and concur in the settlement and compromise of these actions. IT Petitioners, further approve the proposed distribution contained in the form Order attached. 18. No hearing is requested. 19. The concurrence of all counsel of record, John R. Zonarich, Esq., Thomas Archer, Esq. and Nicole L. Bordo, Esq., was sought and all counsel concur in the Petition. WHEREFORE, Petitioner, Nancy Rogowicz, the parent and natural guardian of Courtney Myers, requests that this Court enter an Order approving the proposed Settlement and Compromise, authorize Petitioner to make distribution pursuant to the Petition, to execute all necessary releases and endorse all checks. Respectfully submitted, Dated: January! :, 2009 BY: C Stephen 4K. Portko, Esq. Bratic & Portko 101 South U.S. Route 15 Dillsburg, PA 17019 .. CERTIFICATE OF SERVICE I, Stephen K. Portko, of Bratic & Portko, hereby certify that I this day served a copy of the foregoing AMENDED PETITION FOR APPROVAL OF MINOR'S SETTLEMENT upon the person(s) indicated below by depositing a copy of the same in the United States Mail, postage prepaid, at Harrisburg, Pennsylvania, and addressed as follows: Nancy Rogowicz 555 Hillcrest Road York, PA 17403 John R. Zonarich, Esquire Skarlatos & Zonarich LLP 17 South Second Street, 6th Fl Harrisburg, PA 17101 Attorneys for Defendants Terri Cassel and Nancy Beinhower Thomas A. Archer, Esquire Archer & Archer P.C. 2515 North Front Street P.O. Box 5056 Harrisburg, Pa 17110 Attorney for Plaintiff, Washington National Insurance Company Nicole L. Borda, Esquire Buchanan Ingersoll & Rooney PC 213 Market Street, 3rd Floor Harrisburg, PA 17101 Attorney for Plaintiff Lincoln National Life Insurance Company Date: January lo, 2009 'aa t a ?v -? RE , D r. 1 cl 3 C) 3 `C E ? JAN 14 20090 Bratic & Portko Stephen K. Portko, Esquire 101 South U.S. Route 15 Dillsburg, PA 17019 Tel: (717) 432-9706 Fax: (717) 432-9220 Email: braticportko@aol.com Attorneys for Defendants, Barry Beinhower, Nancy Rogowicz and Courtney Myers, a Minor Child IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA WASHINGTON NATIONAL INSURANCE COMPANY, CIVIL ACTION - EQUITY Plaintiff, V. CASE NO. 07-6648 CIVIL TERM #**' BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower, Defendants. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA LINCOLN NATIONAL LIFE INSURANCE COMPANY, CIVIL ACTION - EQUITY d/b/a LINCOLN FINANCIAL GROUP Plaintiff, V. CASE NO. 08-2526 CIVIL TERM BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI CASSEL, Executrix of the Estate of Clair Beinhower, Defendants. ORDER AND NOW, this 2-(, - day of , 2009, upon consideration of the Petition for Approval of Minor's Settlement, it is hereby ordered that the Petitioners are v -r a authorized to enter into the settlement with Washington National Insurance Company and Lincoln National Life Insurance Company d/b/a Lincoln Financial Group in accordance with the proposed distributions as outlined in the Petition and Settlement Agreements and Releases. Counsel shall provide to the Court, within ten (10) days from the date of this order, proof of such deposit. Petitioners are authorized to sign the necessary releases and other documents to conclude the Minor Courtney Myer's claims to the Insurance Annuity Proceeds. By the Court: Archer & Archer, P.G By: Thomas A. Archer, Esquire 2515 North Front Street P.O. Box 5056 Harrisburg, PA 17110 tarcher@archerandarcher.com Attorney for Plaintiff, Washington National Insurance Company WASHINGTON NATIONAL INSURANCE COMPANY, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA. Plaintiff, V. CIVIL ACTION - EQUITY BARRY BEINHOWER, NANCY ROGOWICZ, COURTNEY MYERS, NANCY BEINHOWER, and TERRI : DOCKET NO.: 07-6648 CIVIL TERM CASSELL, Executrix of the Estate of Clair Beinhower, Defendants. PRAECIPE TO SETTLE, DISCONTOWE AND END TO: PROTHONOTARY Please mark the above case as settled, discontinued and ended with prejudice. Date: April 15, 2009 By: Thomas A. Archer, Esquire 2515 North Front Street, PO Box 5056 Harrisburg, PA 17110 (717) 233-8676 Attorney for Plaintiff CERTIFICATE OF SERVICE I, Jessica Porter, Paralegal, hereby certify that on the date set forth below I served a true and correct copy of the foregoing Praecipe to Settle, Discontinue and End upon the person(s) stated below, via U.S. Mail, postage prepaid, addressed as follows: John R Zonarich, Esquire Skarlatus & Zonarich, LLP 17 South Second Street, Oh Floor Harrisburg, PA 17101 Attorney for Terri Cassel and Nancy Beinhower Stephen K. Portko, Esquire Bratic & Portko 101 South U.S. Route 15 Dillsburg, PA 17019 Attorney for Barry Beinhower, Nancy Rogowicz and Courtney Myers Date: April 15, 2009 OA?Jessica Porter, Paralegal FILED-43 FLI E OF THE F TO 13'PNOTARY 2009 APR 16 P 3: 3 4 CU";, `? r ??? N' A