Member Companies: Administrator for:

Great American Life Insurance Company® Continental General Insurance Company®

Annuity Investors Life Insurance Company® Loyal American Life Insurance Company®
Manhattan National Life Insurance Company
Fixed & Fixed Indexed Annuities: PO Box 5420, Cincinnati OH 45201 / 800-854-3649 / 800-482-8126 Fax
Variable & Registered Index-Linked Annuities: PO Box 5423, Cincinnati OH 45201 / 800-789-6771 / 513-768-5115 Fax
Overnight Address: 10th Floor, 301 E Fourth St, Cincinnati OH 45202

Notice and Customer Information Form for Individual Annuity Contracts

To help the government fight the funding of terrorism and money laundering activities, Federal law requires us to obtain all
relevant customer-related information necessary to run an effective anti-money laundering program.

What this means to you: When submitting a request for a contract disbursement or other contract changes, we ask that the
owner(s) provide name, address, date of birth, tax identification number and other customer-related information that will allow
us to identify you and fulfill our obligations under Federal law. Picture documentation, such as a current driver’s license or
other valid identifying documents, will be used to verify the information and MUST be included when submitting this form.

By acknowledging receipt of this Notice and Customer Information Form, the undersigned authorizes any law enforcement
agency, public or private institution, information service bureau or other entity contacted by the Company(ies) identified above
to furnish information sufficient to confirm the personal information of the undersigned as required by Federal law. This
information is confidential and will not be used for any other purpose. The undersigned hereby release(s) all persons, agents
and agencies, and entities providing confirming information from any and all liability arising out of the request for or the
release of confirming information.

Please fully complete all applicable sections. Incomplete or unclear requests may result in processing delays.

1. OWNER INFORMATION (MUST fully complete and attach supporting documentation.)

PRIMARY OWNER
Owner Name Contract Number / Company Name

Street Address
Retired: Yes No

City, State and Zip

Current Occupation*:
Daytime Phone Number

Current Employer*:
Social Security Number / FEIN

Date of Birth
*If retired, please list your former occupation/employer.

Verification of ID: State/Country:

Driver’s License/State ID Number:
Passport Date Issued:
Other Exp. Date:
Owner is an entity; legal document(s) attached
(e.g. Articles of Incorporation, Trust Agreements, etc.)

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JOINT OWNER (if applicable)
Joint Owner Name
Retired: Yes No

Street Address
Current Occupation*:

City, State and Zip

Current Employer*:
Social Security Number / FEIN

Date of Birth
*If retired, please list your former occupation/employer.

Verification of ID: State/Country:

Driver’s License/State ID Number:
Passport Date Issued:
Other Exp. Date:

2. CONTRACT REQUEST TYPE (MUST check one box for each section as applicable)
2

A) TYPE OF REQUEST

Partial Withdrawal Full Surrender Annuitization

B) DISTRIBUTION TYPE

PAYMENT TO OWNER, ANNUITANT, or PARTICIPANT

DIRECT TRANSFER, DIRECT ROLLOVER, OR 1035 EXCHANGE

Company to receive the funds:

C) REQUEST REASON

The purpose of this transaction:

(For example: funds will be used to pay for college expense, to purchase a home, etc.)

3. OWNER CERTIFICATION

The Owner(s) acknowledges the forgoing notice and certifies that the foregoing information is true and correct to the best of
my knowledge and belief.

Owner’s Printed Name Joint Owner’s Printed Name

Owner’s Signature Date Joint Owner’s Signature Date

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