WIXLIB

Disability declarationPlease have your physician read, sign and return this form with your request.Client name Contract/Certificate numberResidents of all states except Massachusetts:Certification of disability as defined by the Internal Revenue Code Section 72(m)(7).As the physician of the above named owner, I certify that he/she is disabled as defined by the following definition of disabilityof IRC Section 72(m)(7):“For purposes of this section, an individual shall be considered to be disabled if he is unable to engage in any substantialgainful activity by reason of any medically determinable physical or mental impairment which can be expected to result indeath or to be long-continued and indefinite duration.”Client signature/datePhysician signature/dateResidents of Massachusetts:Certification of disability as defined by Massachusetts law:As the physician of the above named owner, I certify that he/she is disabled as defined as any of the following conditions:(check one of the following) Chronic Illness defined as a condition because of which an individual is (a) unable to perform at least two activities of dailyliving for a period of 90 days due to a loss of functional capacity, (b) having a level of disability similar to the level ofdisability described above, or (c) requiring substantial supervision to protect such individuals from threats to health andsafety due to severe cognitive impairment. Terminal Illness is defined as a condition that will reasonably be expected to result in death in 24 months or less. Any medical condition including but not limited to acquired immune deficiency syndrome, coronary artery disease, majororgan transplant, medical condition requiring continuous life support, permanent neurological deficit resulting fromcerebral vascular accident, or other qualifying condition.Client name signature/datePhysician signature/dateIn cases that the individual qualifies for benefits because of Chronic Illness only, the benefit amount shall be payable only forexpenses incurred for Qualified Long-Term Care Services defined as the necessary diagnostic, preventive, therapeutic curing,treating, mitigating and rehabilitative services, and maintenance or personal care services that are required by a chronically illindividual and are provided pursuant to a plan of care prescribed by a licensed health care practitioner.I the owner, certify that any benefits paid solely due to Chronic Illness would be used to fund Qualified Long-Term CareServices.Client signature/dateIA-004052 (5/13)Page 4 of 13

The following pages are for your retention; not necessary to return to Horace MannAnnuity contract investment options; certain group annuities may be further limited by their planInvestment styleInvestment option # Investment option nameLife Cycle063Wilshire VIT 2015 ETF Fund064Wilshire VIT 2025 ETF Fund065Wilshire VIT 2035 ETF FundAsset Allocation076Ibbotson Conservative ETF Asset Allocation Portfolio Class II077Ibbotson Income & Growth ETF Asset Allocation Portfolio Class II078Ibbotson Balanced ETF Asset Allocation Portfolio Class II079Ibbotson Growth ETF Asset Allocation Portfolio Class II080Ibbotson Aggressive Growth ETF Asset Allocation Portfolio Class IILarge Company Value027Davis Value Portfolio055T. Rowe Price Equity Income Portfolio VIP II014Wilshire Large Company Value PortfolioLarge Company Core020Fidelity VIP Growth and Income Portfolio (SC2)021Fidelity VIP Index 500 Portfolio (SC2)069JP Morgan Insurance Trust U.S. Equity Portfolio012(010)Wilshire 5000 Index Portfolio - (used prior to 9/5/00)001Wilshire VIT Equity FundLarge Company Growth033AllianceBernstein VPS Large Cap Growth Portfolio082Delaware VIP 53 'ROWTH 3ERIES 3ERVICE Class023Fidelity VIP Growth Portfolio (SC2)013(011)Wilshire Large Company Growth Portfolio (used prior to 9/5/00)Mid-size Company Value056AllianceBernstein VPS Small/Mid Cap Value081American Century VP Mid Cap Value Class I037Ariel Appreciation Fund036Ariel Fund070Goldman Sachs VIT Mid Cap Value028Wells Fargo Advantage VT Opportunity FundMid-size Company Core071Calvert S & P Mid Cap 400 Index051Dreyfus Inv Portfolio: Mid Cap Stock Portfolio (SC)022Fidelity VIP Mid Cap Portfolio (SC2)031Rainier Small/Mid Cap Equity PortfolioMid-size Company Growth048Delaware VIP Smid Cap Growth Series SC049Lord Abbett Series Fund Growth Opportunities075Putnam VT Multi-Cap Growth Fund054Wells Fargo Advantage VT Discovery FundSmall Company Value053Royce Capital Fund Small Cap Portfolio017T Rowe Price Small Cap Value Fund015Wilshire Small Company Value PortfolioSmall Company Core068Dreyfus: Small Cap Stock Index Portfolio SC050Goldman Sachs VIT Structured Small Cap Equity Fund072Lazard Ret US Small-Mid Cap Equity Portfolio032Neuberger Berman Genesis Fund (Advisor Class)018T Rowe Price Small Cap Stock FundSmall Company Growth057AllianceBernstein VPS Small Cap Growth Portfolio092Lord Abbett Developing Growht Portfolio016Wilshire Small Company Growth Portfolio009Wilshire VIT Small Cap Growth FundInternational073Fidelity VIP Emerging Markets SC2024Fidelity VIP Overseas Portfolio (SC2)008Wilshire VIT International Equity FundSpecialty007Wilshire VIT Socially Responsible FundReal Estate067Delaware VIP REIT Series (Service Class)Bond Options025Fidelity VIP High Income Portfolio (SC2)026Fidelity VIP Investment Grade Bond Portfolio (SC2)074Templeton Global Bond Securities Fund003Wilshire VIT Income FundBalanced002Wilshire VIT Balance FundMoney Market059T Rowe Price Prime Reserve PortfolioFixed000Fixed Account8055 year Guarantee Period Acct (variable group products only)8077 year Guarantee Period Acct (variable group products only)81010 year Guarantee Period Acct (variable group products only)8155 year Guarantee Period Acct (fixed group products only)8177 year Guarantee Period Acct (fixed group products only)82010 year Guarantee Period Acct (fixed group products only)900Special DCA Holding Account (unavailable to contracts issued in Oregon)901Special 3-month DCA Account (unavailable to contracts issued in Oregon)902Special 6-month DCA Account (unavailable to contracts issued in Oregon)903Special 12-month DCA Account (unavailable to contracts issued in Oregon)998Loan AccountIA-004052 (5/13)Page 5 of 13

Special tax notice for payments NOT from a Designated Roth accountThis notice is based, in part, on an Internal Revenue Servicemodel notice and as a result, certain sections of the noticemay not be applicable to your Plan.How do I do a rollover?Your rollover optionsIf you do a direct rollover, the Plan will make the paymentdirectly to your IRA or an employer plan. You should contactthe IRS sponsor or the administrator of the employer planfor information on how to do a direct rollover.You are receiving this notice because all or a portion of apayment you are receiving from a Horace Mann LifeInsurance Company annuity issued under a tax qualifiedplan, section 403(b) plan or governmental section 457(b)plan (the “Plan”) is eligible to be rolled over to an IRA or anemployer plan. This notice is intended to help you decidewhether to do such a rollover.This section of the notice describes the rollover rules thatapply to payments from the Plan that are not from adesignated Roth account (a type of account with special taxrules in some employer plans). If you also receive a paymentfrom a designated Roth account in the Plan, you should readthe “Special tax notice for payments from a Designated Rothaccount” latter in this document, and the Plan administratoror the payor will tell you the amount that is being paid fromeach account.Rules that apply to most payments from a plan are describedin the “General Information About Rollovers” section.Special rules that only apply in certain circumstances aredescribed in the “Special Rules and Options” section.General information about rolloversHow can a rollover affect my taxes?You will be taxed on a payment from the Plan if you do notroll it over. If you are under age 59 1/2 and do not do arollover, you will also have to pay a 10% additional incometax on early distributions (unless an exception applies).However, if you do a rollover, you will not have to pay taxuntil you receive payments later and the 10% additionalincome tax will not apply if those payments are made afteryou are age 59 1/2 (or if an exception applies).Where may I roll over the payment?You may roll over the payment to either an IRA (anindividual retirement account or individual retirementannuity) or an employer plan (a tax-qualified plan, section403(b) plan, or governmental section 457(b) plan) that willaccept the rollover. The rules of the IRA or employer planthat holds the rollover will determine your investmentoptions, fees, and rights to payment from the IRA oremployer plan (for example, no spousal consent rules applyto IRAs and IRAs may not provide loans). Further, theamount rolled over will become subject to the tax rules thatapply to the IRA or employer plan.IA-004052 (5/13)There are two ways to do a rollover. You can do either adirect rollover or a 60-day rollover.If you do not do a direct rollover, you may still do a rollover bymaking a deposit into an IRA or eligible employer plan thatwill accept it. You will have 60 days after you receive thepayment to make the deposit. If you do not do a directrollover, the Plan is required to withhold 20% of thepayment for federal income taxes (up to the amount of cashand property received other than employer stock). Thismeans that, in order to roll over the entire payment in a60-day rollover, you must use other funds to make up for the20% withheld. If you do not roll over the entire amount ofthe payment, the portion not rolled over will be taxed andwill be subject to the 10% additional income tax on earlydistributions if you are under age 59 1/2 (unless an exceptionapplies).How much may I roll over?If you wish to do a rollover, you may roll over all or part ofthe amount eligible for rollover. Any payment from the Planis eligible for rollover, except: Certain payments spread over a period of at least 10 yearsor over your life or life expectancy (or the lives or jointlife expectancy of you and your beneficiary) Required minimum distributions after age 70 1/2 (orafter death) Hardship distributions Corrective distributions of contributions that exceed taxlaw limitations Loans treated as deemed distributions (for example, loansin default due to missed payments before youremployment ends) Cost of life insurance paid by the Plan Contributions made under special automatic enrollmentrules that are withdrawn pursuant to your request within90 days of enrollment.The Plan administrator or the payor can tell you whatportion of a payment is eligible for rollover.Page 6 of 13

If I don't do a rollover, will I have to pay the10% additional income tax on earlydistributions?If you are under age 59 1/2, you will have to pay the 10%additional income tax on early distributions for any paymentfrom the Plan (including amounts withheld for income tax)that you do not roll over, unless one of the exceptions listedbelow applies. This tax is in addition to the regular incometax on the payment not rolled over. The 10% additionalincome tax does not apply to the following payments fromthe Plan: Payments made after you separate from service if you willbe at least age 55 in the year of the separation. Payments that start after you separate from service if paidat least annually in equal or close to equal amounts overyour life or life expectancy (or the lives or joint lifeexpectancy of you and your beneficiary) The exception for payments made at least annually inequal or close to equal amounts over a specified periodapplies without regard to whether you have had aseparation from service. The exception for qualified domestic relations orders(QDROs) does not apply (although a special rule appliesunder which, as part of a divorce or separationagreement, a tax-free transfer may be made directly to anIRA of a spouse or former spouse). There are additional exceptions for (1) payments forqualified higher education expenses, (2) payments up to 10,000 used in a qualified first-time home purchase,and eligible to receive unemployment compensation butfor self-employed status). Payments made due to disabilityWill I owe State income taxes?This notice does not describe any State or local income taxrules (including withholding rules). Payments after your deathSpecial rules and options Corrective distributions of contributions that exceed taxlaw limitations Cost of life insurance paid by the Plan. Contributions made under special automatic enrollmentrules that are withdrawn pursuant to your request within90 days of enrollment Payments made directly to the government to satisfy afederal tax levy Payments made under a qualified domestic relationsorder (QDRO). Payments up to the amount of your deductible medicalexpenses Certain payments made while you are on active duty ifyou were a member of a reserve component called toduty after September 11, 2001 for more than 179 days.If I do a rollover to an IRA, will the 10%additional income tax apply to earlydistributions from the IRA?If you receive a payment from an IRA when you are underage 59 1/2, you will have to pay the 10% additional incometax on early distributions from the IRA, unless an exceptionapplies. In general, the exceptions to the 10% additionalincome tax for early distributions from an IRA are the sameas the exceptions listed above for early distributions from aplan. However, there are a few differences for payments froman IRA, including: There is no exception for payments after separation fromservice that are made after age 55.IA-004052 (5/13)If your payment includes after-taxcontributionsAfter-tax contributions included in a payment are not taxed.If a payment is only part of your benefit, an allocable portionof your after-tax contributions is generally included in thepayment. If you have pre-1987 after-tax contributionsmaintained in a separate account, a special rule may apply todetermine whether the after-tax contributions are included ina payment.You may roll over to an IRA a payment that includes after-taxcontributions through either a direct rollover or a 60-dayrollover. You must keep track of the aggregate amount of theafter-tax contributions in all of your IRAs (in order todetermine your taxable income for later payments from theIRAs). If you do a direct rollover of only a portion of theamount paid from the Plan and a portion is paid to you, eachof the payments will include an allocable portion of theafter-tax contributions. If you do a 60-day rollover to an IRAof only a portion of the payment made to you, the after-taxcontributions are treated as rolled over last. For example,assume you are receiving a complete distribution of yourbenefit which totals 12,000, of which 2,000 is after-taxcontributions. In this case, if you roll over 10,000 to an IRAin a 60-day rollover, no amount is taxable because the 2,000amount not rolled over is treated as being after-taxcontributions.You may roll over to an employer plan all of a payment thatincludes after-tax contributions, but only through a directrollover (and only if the receiving plan separately accounts forafter-tax contributions and is not a governmental section457(b) plan). You can do a 60-day rollover to an employerplan of part of a payment that includes after-taxcontributions, but only up to the amount of the paymentthat would be taxable if not rolled over.Page 7 of 13

If you miss the 60-day rollover deadlineGenerally, the 60-day rollover deadline cannot be extended.However, the IRS has the limited authority to waive thedeadline under certain extraordinary circumstances, such aswhen external events prevented you from completing therollover by the 60-day rollover deadline. To apply for awaiver, you must file a private letter ruling request with theIRS. Private letter ruling requests require the payment of anonrefundable user fee. For more information, see IRSPublication 590, Individual Retirement Arrangements(IRAs).If you have an outstanding loan that isbeing offsetIf you have an outstanding loan from the Plan, your Planbenefit may be offset by the amount of the loan, typicallywhen your employment ends. The loan offset amount istreated as a distribution to you at the time of the offset andwill be taxed (including the 10% additional income tax onearly distributions, unless an exception applies) unless you doa 60-day rollover in the amount of the loan offset to an IRAor employer plan.If you were born on or before January 1,1936If you were born on or before January 1, 1936 and receive alump sum distribution that you do not roll over, special rulesfor calculating the amount of the tax on the payment mightapply to you. For more information, see IRS Publication 575,Pension and Annuity Income.If your payment is from a governmentalsection 457(b) planIf the Plan is a governmental section 457(b) plan, the samerules described elsewhere in this notice generally apply,allowing you to roll over the payment to an IRA or anemployer plan that accepts rollovers. One difference is that, ifyou do not do a rollover, you will not have to pay the 10%additional income tax on early distributions from the Planeven if you are under age 59 1/2 (unless the payment is froma separate account holding rollover contributions that weremade to the Plan from a tax-qualified plan, a section 403(b)plan, or an IRA). However, if you do a rollover to an IRA orto an employer plan that is not a governmental section457(b) plan, a later distribution made before age 59 1/2 willbe subject to the 10% additional income tax on earlydistributions (unless an exception applies). Other differencesare that you cannot do a rollover if the payment is due to an“unforeseeable emergency” and the special rules under “if youwere born on or before January 1, 1936”, do not apply.If you roll over your payment to a Roth IRAYou can roll over a payment from the Plan made beforeJanuary 1, 2010 to a Roth IRA only if your modifiedadjusted gross income is not more than 100,000 for the yearthe payment is made to you and, if married, you file a jointreturn. These limitations do not apply to payments made toyou from the Plan after 2009. If you wish to roll over thepayment to a Roth IRA, but you are not eligibleIA-004052(5/13)to do a rollover to a Roth IRA until after 2009, you can do arollover to a traditional IRA and then, after 2009, elect toconvert the traditional IRA into a Roth IRA.If you roll over the payment to a Roth IRA, a special ruleapplies under which the amount of the payment rolled over(reduced by any after-tax amounts) will be taxed. However,the 10% additional income tax on early distributions will notapply (unless you take the amount rolled over out of theRoth IRA within 5 years, counting from January 1 of theyear of the rollover). For payments from the Plan during2010 that are rolled over to a Roth IRA, the taxable amountcan be spread over a 2-year period starting in 2011.If you roll over the payment to a Roth IRA, later paymentsfrom the Roth IRA that are qualified distributions will not betaxed (including earnings after the rollo

sheltered annuity and waive the 30 day notice period, if applicable. I acknowledge full responsibility for any and all federal and state income taxes and penalties. Furthermore, by signing this Annuity surrender/withdrawal request, I certify to the validity of the representations made to Horace Mann Life Insurance Company (HMLIC). I hold HMLIC .