SECTION VI - Existing Insurance

S0602 Accessing Your Annuity Death Benefit

Does the applicant have any existing policies and/or annuities? Yes No (Applicant to check box) Value Through Withdrawals/
If yes, will the annuity applied for replace any of the existing insurance or annuity? Yes No (Applicant to check box) Payment Options
If yes, provide_____________________________________________________________ and complete appropriate replacement and exchange forms. RetireMax® Millennium Plus offers multiple
(Name of Company) options to access all or part of your annuity value.
Withdrawals and payouts are subject to current IRS
SECTION VII - Remarks S0701 regulations. You may choose one of these options at
any time when permitted by law.
Withdrawals – After the first annuity year, you
may withdraw up to 10% of your Accumulation Val-
ue each annuity year with no charge. All withdraw-
SECTION VIII - For Home Office Endorsement Only S0801 als from annuities purchased with qualified monies
(Not applicable in Pennsylvania or West Virginia) are taxed as ordinary income (except withdrawals
from Roth IRAs subject to IRS limitations). Under
certain conditions the IRS may impose a penalty
tax on withdrawals made prior to age 59½. Under
current tax law, all withdrawals from an annuity
SECTION IX – Fraud Warnings and Notices S0901 purchased with non-qualified monies are taxable to
DC/WA – It is a crime to knowingly provide false incomplete or misleading information to an insurance company for the purposes of defrauding the company. the extent there is a gain in the policy. The mini-
Penalties include imprisonment, fines and denial of insurance benefits. FL – Notice: Any person who knowingly and with intent to injure, defraud, or deceive any
insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony in the third degree. KY/ME/OH mum withdrawal is $500, and you must maintain
If you are the Annuitant and you die while this
annuity is in force, LSW will pay the Accumula-
tion Value to your Beneficiary as a Death Benefit
and will waive any remaining Withdrawal Charges.
If you are the Owner but not the Annuitant, the
Death Benefit will equal the Cash Value. If death
occurs after a payout option has been selected, the
Death Benefit, if any, will depend on the payout
option selected.
Defined Terms:
Accumulation Value is your initial premium†, plus
With RetireMax
Millennium Plus,
credited interest, minus any cash withdrawals and
Withdrawal Charges assessed. RetireMax®
you can select
Cash Value is the Accumulation Value less appli-
the retirement option cable Withdrawal Charges.
to fit your needs.
Highlights
• Enjoy tax-deferred growth
• 5% additional first-year interest

PLUS
– Any person who knowingly and with intent to injure, defraud, or deceive any insurer files an application for insurance containing any materially false information at least $5,000 in your annuity to keep it in force.
or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. LA-Any person • No administration fees3
who knowingly presents false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of Payment Options1 – There is no Withdrawal Charge if you elect a • Partial withdrawal provisions
a crime and may be subject to fines and confinement in prison. NJ – Notice: Any person who includes any false or misleading information on an application for formal Payment Option after five years. Your annuity offers a num- • 403(b)/457(b) loan rider
an insurance policy is subject to criminal and civil penalties. AR/NM/PA – Warning: Any person who knowingly and with intent to defraud any insurance company ber of formal Payment Options including: • Annual account statement
or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. VA • Nursing Care Rider (in states where approved) at no additional
– Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or • Installment Income – This is an ideal choice if you want to cost to you
deceptive statement may have violated state law. Notice to Residents of AZ: The annuity to which this application is attached may be returned within 31 days after receive your money over a fixed period of 10 to 25 years.
it is received. Return it to our Home Office or to the agent through whom it was purchased. If returned, we will cancel the annuity and return any premium paid. • Life Income Options – You cannot outlive your income. LSW Annuity Provisions
Upon written request from the Owner, we will provide within a reasonable time, factual information regarding the benefits and provisions of the annuity to which this

LSW’s
will continue to pay you as long as you live. If you elect a joint • Minimum premium: $5,000
application is attached. life option, LSW will pay you or your surviving spouse as long • Maximum premium: Issue Ages 0-75 $1,000,000. Issue Ages
as either of you are living. These choices can even be combined 76-80 $500,0004
SECTION X - Acknowledgments with a guaranteed minimum number of years for payment.

Single Premium
S1003 • Issue age: Annuitant/Owner – up to age 80 (actual age);
The Annuitant and the Owner, if other than the Annuitant; (1) represents, to the best of their knowledge and belief, that all statements and answers contained herein Individual Owner and Annuitant must be the same person
are full, complete and true as written and are correctly recorded; and, (2) expressly agrees as follows: Nursing Care Rider2 • Plan Options: Qualified and Non-qualified
LSW’s RetireMax® Millennium Plus includes a Nursing Care
Deferred Annuity Series
1. This application and the answers and agreements contained herein shall be the basis of, a part of the consideration for and a part of the annuity hereby applied for. • Withdrawal Charges waived on the death of the Annuitant
2. The payment of premium constitutes consideration to the Company for the granting of an annuity and upon payment becomes the absolute property of the Company. Rider that will eliminate Withdrawal Charges for policyowners who • This Policy is not contestable
3. If proof of age is not given with this application, the Annuitant(s) will furnish the Company with such proof before annuity payments begin. require long term care if: • A Withdrawal Charge may apply on amounts withdrawn in excess
4. The annuity applied for shall take effect on the date the premium is received by the Company in its Home Office. The SecurePlus single premium deferred annuities of free withdrawal
• the owner (under age 76 on the issue date of the Policy) stays
shall take effect on the 7th, 14th, 21st or 28th of the month following or coincident with the date the premium is received by the Company in its Home Office.
in a hospital and/or professional long term care facility for 60
5. The Company is authorized to amend this application by an appropriate notation in the space designated “For Home Office Endorsement Only” in order to Withdrawal Charges
days or longer. Withdrawal requests and documentation must
correct apparent errors or omissions. The acceptance of any annuity issued on this application shall constitute acceptance and ratification of the beneficiary be filed no later than 60 days after the end of the stay;
designation, if any, in such annuity and of any amendments contemplated above except that no change shall be made in the plan of annuity or benefits without Policy Year 1 2 3 4 5 6 7 8 9 10 11+
the written acceptance of the Annuitant(s) or of the Owner if other than the Annuitant(s).
• the policy has been in force longer than one year when the
Withdrawal
owner’s hospital and/or long term care stay begins;
W9: Under the penalties of perjury, I certify that: (1) the number shown on this application is my correct taxpayer identification number; (2) the IRS has never Charge 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0%
• the maximum aggregate withdrawal for all of the owner’s
notified me that I am subject to backup withholding, or has notified me that I am no longer subject to such withholding or I am exempt from such withholding; and
(3) I am a U.S. person (including a U.S. resident alien). You must cross out item 2 if you have been notified by the IRS that you are currently subject to backup
policies with this benefit does not exceed $250,000.
1 Benefits at annuitization could be reduced if a misstatement of age or sex
withholding because of underreporting interest or dividends on your tax return. has occurred.
If the owner is 76 or older on the issue date of the Policy, all of the
above provisions will apply. However, the waiver of Withdrawal 2 Nursing Care Rider not available in IL, LA, MA, MT, NH, NJ, PA, SC, WA,
WV, WI. Restrictions and additional conditions apply, refer to Rider Form
SECTION XI - Signature and Agent Information S1101 Charges will apply to a maximum of 25% of the Accumulation No. 7648.
Value with only one withdrawal allowed.
Dated at (city/state)___________________________________on (month/day/year)___________________________________________________ 3 A few states require the payment of premium taxes on annuities either at the
time the Company receives the premium, upon annuitization or withdrawal.
Life Insurance Company of the Southwest
Signature of Owner_ __________________________________Signature of Annuitant (if different from Owner)________________________________ If LSW must pay such taxes, we will deduct them from the Policy benefits. A Member of the National Life Group®
Signature of Joint Owner (if applicable)______________________________________ 4 Subject to change without notice.
To the best of my knowledge, a replacement________________ is is not involved in this transaction. (Agent to check box.) Florida License ID No._ _________ Note: There are special rules for annuities owned by trusts, corporate entities or
Signature of Agent_ _____________________________ Soliciting Agent (print)_ _______________________ Agent No.______________ Percent______
Form No. 9386 (1106)
qualified plans.
RetireMax Millennium Plus is Policy Form No. 7885. Loans are provided to
Protecting Your Retirement Savings
Agent Phone Number____________________________ Other Agent (print)___________________________ Agent No.______________ Percent______ Cat. No. 100718 403(b) and 457 policies by endorsement in states where approved.

Integrity You
Can Retire On!
You’ve worked hard and steadily stashed away
savings. But your retirement dream can turn into a
nightmare if you end up outliving your savings. As life
expectancy rates climb, people are living in retirement
much longer than previous generations. And it’s hap-
pening when Social Security and pensions are becom-
ing less secure.
If working longer and spending less during your
retirement years don’t appeal to you, you should craft
a solid retirement plan today that considers the risks of
longevity, inflation and market downturns. The longer
you live, the greater chance that you may outlive your
assets in retirement. Health care costs, inflation and
market downturns can erode your future buying power
and savings.
If a couple wants an annual retirement income of
$85,000 and intends to stop working at age 65, they’ll
need about $838,000 in savings to supplement their
Social Security income for 20 years. This example
assumes a 7 percent rate of return and 4 percent
inflation rate.
But if they both live to 100, they’ll need more than
one-and-a-half times that amount — a portfolio worth
about $1.3 million — in order to preserve the same
lifestyle in retirement.
Accumulate More for Retirement
RetireMax® Millennium Plus is a single premium
deferred annuity and a long-term savings vehicle that
may be an excellent addition to your overall financial
retirement plan. RetireMax® Millennium Plus can be a
great way to accumulate money for retirement, if you
want retirement income beyond what you will receive
from Social Security or a pension plan. Your money
grows tax deferred, which means you pay no taxes on
earnings until you begin to withdraw your money. You
also can provide death benefits to your heirs. If you
die prematurely, RetireMax® Millennium Plus can offer
a death benefit to your beneficiaries without the costs
and delays of probate.
Application for Annuity
Life Insurance Company of the Southwest (LSW) • 1300 W. Mockingbird Ln. • Dallas, TX 75247-4921 • Customer Service 800-579-2878
Section I - Owner/Joint Owner/Annuitant
Owner’s Name SS No or Taxpayer ID DOB (m/d/yy) Age
S0107
Sex
Home Address City State Zip Code
About the Company
Even when an annuity seems to be the right fit for your financial
Home Phone Number Home Fax Number Home e-mail Address
plan, you want the reassurance that your money is safe. RetireMax® RetireMax
Millennium Plus is backed by the full assets of Life Insurance Company
Millennium Plus Annuitant’s Name (if different from Owner) SS No or Taxpayer ID DOB (m/d/yy) Age Sex
of the Southwest. LSW has a corporate investment policy that strongly
emphasizes quality investments and safety. may give you peace
Home Address City State Zip Code
LSW was incorporated in 1955 under the laws of Texas as a legal of mind knowing
reserve insurance company. The Company is licensed in 49 states and your money is safe.
Home Phone Number Home Fax Number Home e-mail Address
the District of Columbia. RetireMax
Millennium Plus
Please Note: Neither LSW nor any of its agents or representatives give Joint Owner’s Name (if applicable, non-qualified only) SS No or Taxpayer ID DOB (m/d/yy) Age Sex
legal, tax, or accounting advice. The information provided here is a summary is backed by the
of our understanding of the current tax laws and regulations as they relate to full assets of LSW. Home Address City State Zip Code
annuities. All prospective purchasers should consult with their own attorneys,
accountants, and tax advisors.
Home Phone Number Home Fax Number Home e-mail Address
If you want further information on this annuity, please contact
your LSW agent or call LSW at the telephone number shown below.
SECTION II - Beneficiary S0201
Life Insurance Company of the Southwest, A Member of the National Life Group® Beneficiary Relationship Share
1300 West Mockingbird Lane, Dallas, Texas 75247-4921 1) %
800-579-2878, www.lifeofsouthwest.com 2) %
Contingent Beneficiary Relationship Share
1) %
2) %
Tax-Deferred Growth annuity, you will receive the Accumulation Value less any outstand-
RetireMax® Millennium Plus is a single premium deferred ing loans and applicable Withdrawal Charges. Applicable With-
drawal Charges are shown on the back panel of this brochure.
annuity that may offer you multiple advantages over alternative
programs. Because it is tax-deferred, you pay no taxes* on earn- SECTION III - Premium S0301
ings until you decide to make a withdrawal.† So... 5% Additional Interest Amount Paid with Application Rollover/Transfer (Approximate) Documentation Submitted With App:
We currently are issuing this Policy with a first-year rate 5% higher
• You earn interest on your premium; than the interest rate guaranteed in the second year. Once issued, Single Transfer(s) or Rollover(s)
• You earn interest on your accumulated interest; these rates are fully guaranteed. Then, interest will be declared
• You earn interest on the earnings that would usually be paid annually and credited daily. When we issue your policy, it will state
in taxes. the minimum interest rate we will credit, which is guaranteed
for the life of the policy. The minimum interest rate is based on a
SECTION IV - Plan Selected S0403
RetireMax Millennium Plus
RetireMax Millennium Plus can be purchased as a qualified or
®
formula established by applicable regulation in your state and will
nonqualified annuity. be between 1% and 3%. For the current minimum guaranteed
interest rate, contact your agent or LSW.
Understanding Your Values SECTION V - Plan Qualification S0503
Your Accumulation Value is your net premium, accumulated at 403 (b) TSA 457 Def. Comp Pension/Profit Sharing IRA ROTH IRA IRA Rollover Non-Qualified
* Unless your annuity is pledged or used as security for a loan.
interest, less withdrawals. If you are the Annuitant and Owner,
the Accumulation Value less any outstanding loans (if applicable),
† A few states require the payment of premium taxes on annuities either Other (specify)_____________________________________________________________________________________________________
at the time the Company receives the premium, upon annuitization or
will be paid to your named Beneficiaries in case of your death, withdrawal. If LSW must pay such taxes, we will deduct them from the
outside the costs and delays of probate. If you withdraw all of your Policy benefits.
Form No. 7909 I MILLENPL Form No. 7909

Integrity You
Can Retire On!
You’ve worked hard and steadily stashed away
savings. But your retirement dream can turn into a
nightmare if you end up outliving your savings. As life
expectancy rates climb, people are living in retirement
much longer than previous generations. And it’s hap-
pening when Social Security and pensions are becom-
ing less secure.
If working longer and spending less during your
retirement years don’t appeal to you, you should craft
a solid retirement plan today that considers the risks of
longevity, inflation and market downturns. The longer
you live, the greater chance that you may outlive your
assets in retirement. Health care costs, inflation and
market downturns can erode your future buying power
and savings.
If a couple wants an annual retirement income of
$85,000 and intends to stop working at age 65, they’ll
need about $838,000 in savings to supplement their
Social Security income for 20 years. This example
assumes a 7 percent rate of return and 4 percent
inflation rate.
But if they both live to 100, they’ll need more than
one-and-a-half times that amount — a portfolio worth
about $1.3 million — in order to preserve the same
lifestyle in retirement.
Accumulate More for Retirement
RetireMax® Millennium Plus is a single premium
deferred annuity and a long-term savings vehicle that
may be an excellent addition to your overall financial
retirement plan. RetireMax® Millennium Plus can be a
great way to accumulate money for retirement, if you
want retirement income beyond what you will receive
from Social Security or a pension plan. Your money
grows tax deferred, which means you pay no taxes on
earnings until you begin to withdraw your money. You
also can provide death benefits to your heirs. If you
die prematurely, RetireMax® Millennium Plus can offer
a death benefit to your beneficiaries without the costs
and delays of probate.
Application for Annuity
Life Insurance Company of the Southwest (LSW) • 1300 W. Mockingbird Ln. • Dallas, TX 75247-4921 • Customer Service 800-579-2878
Section I - Owner/Joint Owner/Annuitant
Owner’s Name SS No or Taxpayer ID DOB (m/d/yy) Age
S0107
Sex
Home Address City State Zip Code
About the Company
Even when an annuity seems to be the right fit for your financial
Home Phone Number Home Fax Number Home e-mail Address
plan, you want the reassurance that your money is safe. RetireMax® RetireMax
Millennium Plus is backed by the full assets of Life Insurance Company
Millennium Plus Annuitant’s Name (if different from Owner) SS No or Taxpayer ID DOB (m/d/yy) Age Sex
of the Southwest. LSW has a corporate investment policy that strongly
emphasizes quality investments and safety. may give you peace
Home Address City State Zip Code
LSW was incorporated in 1955 under the laws of Texas as a legal of mind knowing
reserve insurance company. The Company is licensed in 49 states and your money is safe.
Home Phone Number Home Fax Number Home e-mail Address
the District of Columbia. RetireMax
Millennium Plus
Please Note: Neither LSW nor any of its agents or representatives give Joint Owner’s Name (if applicable, non-qualified only) SS No or Taxpayer ID DOB (m/d/yy) Age Sex
legal, tax, or accounting advice. The information provided here is a summary is backed by the
of our understanding of the current tax laws and regulations as they relate to full assets of LSW. Home Address City State Zip Code
annuities. All prospective purchasers should consult with their own attorneys,
accountants, and tax advisors.
Home Phone Number Home Fax Number Home e-mail Address
If you want further information on this annuity, please contact
your LSW agent or call LSW at the telephone number shown below.
SECTION II - Beneficiary S0201
Life Insurance Company of the Southwest, A Member of the National Life Group® Beneficiary Relationship Share
1300 West Mockingbird Lane, Dallas, Texas 75247-4921 1) %
800-579-2878, www.lifeofsouthwest.com 2) %
Contingent Beneficiary Relationship Share
1) %
2) %
Tax-Deferred Growth annuity, you will receive the Accumulation Value less any outstand-
RetireMax® Millennium Plus is a single premium deferred ing loans and applicable Withdrawal Charges. Applicable With-
drawal Charges are shown on the back panel of this brochure.
annuity that may offer you multiple advantages over alternative
programs. Because it is tax-deferred, you pay no taxes* on earn- SECTION III - Premium S0301
ings until you decide to make a withdrawal.† So... 5% Additional Interest Amount Paid with Application Rollover/Transfer (Approximate) Documentation Submitted With App:
We currently are issuing this Policy with a first-year rate 5% higher
• You earn interest on your premium; than the interest rate guaranteed in the second year. Once issued, Single Transfer(s) or Rollover(s)
• You earn interest on your accumulated interest; these rates are fully guaranteed. Then, interest will be declared
• You earn interest on the earnings that would usually be paid annually and credited daily. When we issue your policy, it will state
in taxes. the minimum interest rate we will credit, which is guaranteed
for the life of the policy. The minimum interest rate is based on a
SECTION IV - Plan Selected S0403
RetireMax Millennium Plus
RetireMax Millennium Plus can be purchased as a qualified or
®
formula established by applicable regulation in your state and will
nonqualified annuity. be between 1% and 3%. For the current minimum guaranteed
interest rate, contact your agent or LSW.
Understanding Your Values SECTION V - Plan Qualification S0503
Your Accumulation Value is your net premium, accumulated at 403 (b) TSA 457 Def. Comp Pension/Profit Sharing IRA ROTH IRA IRA Rollover Non-Qualified
* Unless your annuity is pledged or used as security for a loan.
interest, less withdrawals. If you are the Annuitant and Owner,
the Accumulation Value less any outstanding loans (if applicable),
† A few states require the payment of premium taxes on annuities either Other (specify)_____________________________________________________________________________________________________
at the time the Company receives the premium, upon annuitization or
will be paid to your named Beneficiaries in case of your death, withdrawal. If LSW must pay such taxes, we will deduct them from the
outside the costs and delays of probate. If you withdraw all of your Policy benefits.
Form No. 7909 I MILLENPL Form No. 7909
SECTION VI - Existing Insurance S0602 Accessing Your Annuity
Does the applicant have any existing policies and/or annuities? Yes No (Applicant to check box) Value Through Withdrawals/
If yes, will the annuity applied for replace any of the existing insurance or annuity? Yes No (Applicant to check box) Payment Options
If yes, provide_____________________________________________________________ and complete appropriate replacement and exchange forms. RetireMax® Millennium Plus offers multiple
(Name of Company) options to access all or part of your annuity value.
Withdrawals and payouts are subject to current IRS
SECTION VII - Remarks S0701 regulations. You may choose one of these options at
any time when permitted by law.
Withdrawals – After the first annuity year, you
may withdraw up to 10% of your Accumulation Val-
ue each annuity year with no charge. All withdraw-
SECTION VIII - For Home Office Endorsement Only S0801 als from annuities purchased with qualified monies
(Not applicable in Pennsylvania or West Virginia) are taxed as ordinary income (except withdrawals
from Roth IRAs subject to IRS limitations). Under
certain conditions the IRS may impose a penalty
tax on withdrawals made prior to age 59½. Under
current tax law, all withdrawals from an annuity the retirement option
SECTION IX – Fraud Warnings and Notices S0901 purchased with non-qualified monies are taxable to
DC/WA – It is a crime to knowingly provide false incomplete or misleading information to an insurance company for the purposes of defrauding the company. the extent there is a gain in the policy. The mini-
Penalties include imprisonment, fines and denial of insurance benefits. FL – Notice: Any person who knowingly and with intent to injure, defraud, or deceive any
insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony in the third degree. KY/ME/OH mum withdrawal is $500, and you must maintain
Death Benefit
If you are the Annuitant and you die while this
annuity is in force, LSW will pay the Accumula-
tion Value to your Beneficiary as a Death Benefit
and will waive any remaining Withdrawal Charges.
If you are the Owner but not the Annuitant, the
Death Benefit will equal the Cash Value. If death
occurs after a payout option has been selected, the
Death Benefit, if any, will depend on the payout
option selected.
Defined Terms:
Accumulation Value is your initial premium†, plus
With RetireMax
Millennium Plus,
credited interest, minus any cash withdrawals and
Withdrawal Charges assessed. RetireMax®
you can select
Cash Value is the Accumulation Value less appli-
cable Withdrawal Charges.
to fit your needs.
Highlights
• Enjoy tax-deferred growth
• 5% additional first-year interest

PLUS
– Any person who knowingly and with intent to injure, defraud, or deceive any insurer files an application for insurance containing any materially false information at least $5,000 in your annuity to keep it in force.
or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. LA-Any person • No administration fees3
who knowingly presents false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of Payment Options1 – There is no Withdrawal Charge if you elect a • Partial withdrawal provisions
a crime and may be subject to fines and confinement in prison. NJ – Notice: Any person who includes any false or misleading information on an application for formal Payment Option after five years. Your annuity offers a num- • 403(b)/457(b) loan rider
an insurance policy is subject to criminal and civil penalties. AR/NM/PA – Warning: Any person who knowingly and with intent to defraud any insurance company ber of formal Payment Options including: • Annual account statement
or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. VA • Nursing Care Rider (in states where approved) at no additional
– Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or • Installment Income – This is an ideal choice if you want to cost to you
deceptive statement may have violated state law. Notice to Residents of AZ: The annuity to which this application is attached may be returned within 31 days after receive your money over a fixed period of 10 to 25 years.
it is received. Return it to our Home Office or to the agent through whom it was purchased. If returned, we will cancel the annuity and return any premium paid. • Life Income Options – You cannot outlive your income. LSW Annuity Provisions
Upon written request from the Owner, we will provide within a reasonable time, factual information regarding the benefits and provisions of the annuity to which this

LSW’s
will continue to pay you as long as you live. If you elect a joint • Minimum premium: $5,000
application is attached. life option, LSW will pay you or your surviving spouse as long • Maximum premium: Issue Ages 0-75 $1,000,000. Issue Ages
as either of you are living. These choices can even be combined 76-80 $500,0004
SECTION X - Acknowledgments with a guaranteed minimum number of years for payment.

Single Premium
S1003 • Issue age: Annuitant/Owner – up to age 80 (actual age);
The Annuitant and the Owner, if other than the Annuitant; (1) represents, to the best of their knowledge and belief, that all statements and answers contained herein Individual Owner and Annuitant must be the same person
are full, complete and true as written and are correctly recorded; and, (2) expressly agrees as follows: Nursing Care Rider2 • Plan Options: Qualified and Non-qualified
LSW’s RetireMax® Millennium Plus includes a Nursing Care
Deferred Annuity Series
1. This application and the answers and agreements contained herein shall be the basis of, a part of the consideration for and a part of the annuity hereby applied for. • Withdrawal Charges waived on the death of the Annuitant
2. The payment of premium constitutes consideration to the Company for the granting of an annuity and upon payment becomes the absolute property of the Company. Rider that will eliminate Withdrawal Charges for policyowners who • This Policy is not contestable
3. If proof of age is not given with this application, the Annuitant(s) will furnish the Company with such proof before annuity payments begin. require long term care if: • A Withdrawal Charge may apply on amounts withdrawn in excess
4. The annuity applied for shall take effect on the date the premium is received by the Company in its Home Office. The SecurePlus single premium deferred annuities of free withdrawal
• the owner (under age 76 on the issue date of the Policy) stays
shall take effect on the 7th, 14th, 21st or 28th of the month following or coincident with the date the premium is received by the Company in its Home Office.
in a hospital and/or professional long term care facility for 60
5. The Company is authorized to amend this application by an appropriate notation in the space designated “For Home Office Endorsement Only” in order to Withdrawal Charges
days or longer. Withdrawal requests and documentation must
correct apparent errors or omissions. The acceptance of any annuity issued on this application shall constitute acceptance and ratification of the beneficiary be filed no later than 60 days after the end of the stay;
designation, if any, in such annuity and of any amendments contemplated above except that no change shall be made in the plan of annuity or benefits without Policy Year 1 2 3 4 5 6 7 8 9 10 11+
the written acceptance of the Annuitant(s) or of the Owner if other than the Annuitant(s).
• the policy has been in force longer than one year when the
Withdrawal
owner’s hospital and/or long term care stay begins;
W9: Under the penalties of perjury, I certify that: (1) the number shown on this application is my correct taxpayer identification number; (2) the IRS has never Charge 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0%
• the maximum aggregate withdrawal for all of the owner’s
notified me that I am subject to backup withholding, or has notified me that I am no longer subject to such withholding or I am exempt from such withholding; and
(3) I am a U.S. person (including a U.S. resident alien). You must cross out item 2 if you have been notified by the IRS that you are currently subject to backup
policies with this benefit does not exceed $250,000.
1 Benefits at annuitization could be reduced if a misstatement of age or sex
withholding because of underreporting interest or dividends on your tax return. has occurred.
If the owner is 76 or older on the issue date of the Policy, all of the
above provisions will apply. However, the waiver of Withdrawal 2 Nursing Care Rider not available in IL, LA, MA, MT, NH, NJ, PA, SC, WA,
WV, WI. Restrictions and additional conditions apply, refer to Rider Form
SECTION XI - Signature and Agent Information S1101 Charges will apply to a maximum of 25% of the Accumulation No. 7648.
Value with only one withdrawal allowed.
Dated at (city/state)___________________________________on (month/day/year)___________________________________________________ 3 A few states require the payment of premium taxes on annuities either at the
time the Company receives the premium, upon annuitization or withdrawal.
Life Insurance Company of the Southwest
Signature of Owner_ __________________________________Signature of Annuitant (if different from Owner)________________________________ If LSW must pay such taxes, we will deduct them from the Policy benefits. A Member of the National Life Group®
Signature of Joint Owner (if applicable)______________________________________ 4 Subject to change without notice.
To the best of my knowledge, a replacement________________ is is not involved in this transaction. (Agent to check box.) Florida License ID No._ _________ Note: There are special rules for annuities owned by trusts, corporate entities or
Signature of Agent_ _____________________________ Soliciting Agent (print)_ _______________________ Agent No.______________ Percent______
Form No. 9386 (1106)
qualified plans.
RetireMax Millennium Plus is Policy Form No. 7885. Loans are provided to
Protecting Your Retirement Savings
Agent Phone Number____________________________ Other Agent (print)___________________________ Agent No.______________ Percent______ Cat. No. 100718 403(b) and 457 policies by endorsement in states where approved.

Integrity You
Can Retire On!
You’ve worked hard and steadily stashed away
savings. But your retirement dream can turn into a
nightmare if you end up outliving your savings. As life
expectancy rates climb, people are living in retirement
much longer than previous generations. And it’s hap-
pening when Social Security and pensions are becom-
ing less secure.
If working longer and spending less during your
retirement years don’t appeal to you, you should craft
a solid retirement plan today that considers the risks of
longevity, inflation and market downturns. The longer
you live, the greater chance that you may outlive your
assets in retirement. Health care costs, inflation and
market downturns can erode your future buying power
and savings.
If a couple wants an annual retirement income of
$85,000 and intends to stop working at age 65, they’ll
need about $838,000 in savings to supplement their
Social Security income for 20 years. This example
assumes a 7 percent rate of return and 4 percent
inflation rate.
But if they both live to 100, they’ll need more than
one-and-a-half times that amount — a portfolio worth
about $1.3 million — in order to preserve the same
lifestyle in retirement.
Accumulate More for Retirement
RetireMax® Millennium Plus is a single premium
deferred annuity and a long-term savings vehicle that
may be an excellent addition to your overall financial
retirement plan. RetireMax® Millennium Plus can be a
great way to accumulate money for retirement, if you
want retirement income beyond what you will receive
from Social Security or a pension plan. Your money
grows tax deferred, which means you pay no taxes on
earnings until you begin to withdraw your money. You
also can provide death benefits to your heirs. If you
die prematurely, RetireMax® Millennium Plus can offer
a death benefit to your beneficiaries without the costs
and delays of probate.
Application for Annuity
Life Insurance Company of the Southwest (LSW) • 1300 W. Mockingbird Ln. • Dallas, TX 75247-4921 • Customer Service 800-579-2878
Section I - Owner/Joint Owner/Annuitant
Owner’s Name SS No or Taxpayer ID DOB (m/d/yy) Age
S0107
Sex
Home Address City State Zip Code
About the Company
Even when an annuity seems to be the right fit for your financial
Home Phone Number Home Fax Number Home e-mail Address
plan, you want the reassurance that your money is safe. RetireMax® RetireMax
Millennium Plus is backed by the full assets of Life Insurance Company
Millennium Plus Annuitant’s Name (if different from Owner) SS No or Taxpayer ID DOB (m/d/yy) Age Sex
of the Southwest. LSW has a corporate investment policy that strongly
emphasizes quality investments and safety. may give you peace
Home Address City State Zip Code
LSW was incorporated in 1955 under the laws of Texas as a legal of mind knowing
reserve insurance company. The Company is licensed in 49 states and your money is safe.
Home Phone Number Home Fax Number Home e-mail Address
the District of Columbia. RetireMax
Millennium Plus
Please Note: Neither LSW nor any of its agents or representatives give Joint Owner’s Name (if applicable, non-qualified only) SS No or Taxpayer ID DOB (m/d/yy) Age Sex
legal, tax, or accounting advice. The information provided here is a summary is backed by the
of our understanding of the current tax laws and regulations as they relate to full assets of LSW. Home Address City State Zip Code
annuities. All prospective purchasers should consult with their own attorneys,
accountants, and tax advisors.
Home Phone Number Home Fax Number Home e-mail Address
If you want further information on this annuity, please contact
your LSW agent or call LSW at the telephone number shown below.
SECTION II - Beneficiary S0201
Life Insurance Company of the Southwest, A Member of the National Life Group® Beneficiary Relationship Share
1300 West Mockingbird Lane, Dallas, Texas 75247-4921 1) %
800-579-2878, www.lifeofsouthwest.com 2) %
Contingent Beneficiary Relationship Share
1) %
2) %
Tax-Deferred Growth annuity, you will receive the Accumulation Value less any outstand-
RetireMax® Millennium Plus is a single premium deferred ing loans and applicable Withdrawal Charges. Applicable With-
drawal Charges are shown on the back panel of this brochure.
annuity that may offer you multiple advantages over alternative
programs. Because it is tax-deferred, you pay no taxes* on earn- SECTION III - Premium S0301
ings until you decide to make a withdrawal.† So... 5% Additional Interest Amount Paid with Application Rollover/Transfer (Approximate) Documentation Submitted With App:
We currently are issuing this Policy with a first-year rate 5% higher
• You earn interest on your premium; than the interest rate guaranteed in the second year. Once issued, Single Transfer(s) or Rollover(s)
• You earn interest on your accumulated interest; these rates are fully guaranteed. Then, interest will be declared
• You earn interest on the earnings that would usually be paid annually and credited daily. When we issue your policy, it will state
in taxes. the minimum interest rate we will credit, which is guaranteed
for the life of the policy. The minimum interest rate is based on a
SECTION IV - Plan Selected S0403
RetireMax Millennium Plus
RetireMax Millennium Plus can be purchased as a qualified or
®
formula established by applicable regulation in your state and will
nonqualified annuity. be between 1% and 3%. For the current minimum guaranteed
interest rate, contact your agent or LSW.
Understanding Your Values SECTION V - Plan Qualification S0503
Your Accumulation Value is your net premium, accumulated at 403 (b) TSA 457 Def. Comp Pension/Profit Sharing IRA ROTH IRA IRA Rollover Non-Qualified
* Unless your annuity is pledged or used as security for a loan.
interest, less withdrawals. If you are the Annuitant and Owner,
the Accumulation Value less any outstanding loans (if applicable),
† A few states require the payment of premium taxes on annuities either Other (specify)_____________________________________________________________________________________________________
at the time the Company receives the premium, upon annuitization or
will be paid to your named Beneficiaries in case of your death, withdrawal. If LSW must pay such taxes, we will deduct them from the
outside the costs and delays of probate. If you withdraw all of your Policy benefits.
Form No. 7909 I MILLENPL Form No. 7909
SECTION VI - Existing Insurance S0602 Accessing Your Annuity
Does the applicant have any existing policies and/or annuities? Yes No (Applicant to check box) Value Through Withdrawals/
If yes, will the annuity applied for replace any of the existing insurance or annuity? Yes No (Applicant to check box) Payment Options
If yes, provide_____________________________________________________________ and complete appropriate replacement and exchange forms. RetireMax® Millennium Plus offers multiple
(Name of Company) options to access all or part of your annuity value.
Withdrawals and payouts are subject to current IRS
SECTION VII - Remarks S0701 regulations. You may choose one of these options at
any time when permitted by law.
Withdrawals – After the first annuity year, you
may withdraw up to 10% of your Accumulation Val-
ue each annuity year with no charge. All withdraw-
SECTION VIII - For Home Office Endorsement Only S0801 als from annuities purchased with qualified monies
(Not applicable in Pennsylvania or West Virginia) are taxed as ordinary income (except withdrawals
from Roth IRAs subject to IRS limitations). Under
certain conditions the IRS may impose a penalty
tax on withdrawals made prior to age 59½. Under
current tax law, all withdrawals from an annuity the retirement option
SECTION IX – Fraud Warnings and Notices S0901 purchased with non-qualified monies are taxable to
DC/WA – It is a crime to knowingly provide false incomplete or misleading information to an insurance company for the purposes of defrauding the company. the extent there is a gain in the policy. The mini-
Penalties include imprisonment, fines and denial of insurance benefits. FL – Notice: Any person who knowingly and with intent to injure, defraud, or deceive any
insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony in the third degree. KY/ME/OH mum withdrawal is $500, and you must maintain
Death Benefit
If you are the Annuitant and you die while this
annuity is in force, LSW will pay the Accumula-
tion Value to your Beneficiary as a Death Benefit
and will waive any remaining Withdrawal Charges.
If you are the Owner but not the Annuitant, the
Death Benefit will equal the Cash Value. If death
occurs after a payout option has been selected, the
Death Benefit, if any, will depend on the payout
option selected.
Defined Terms:
Accumulation Value is your initial premium†, plus
With RetireMax
Millennium Plus,
credited interest, minus any cash withdrawals and
Withdrawal Charges assessed. RetireMax®
you can select
Cash Value is the Accumulation Value less appli-
cable Withdrawal Charges.
to fit your needs.
Highlights
• Enjoy tax-deferred growth
• 5% additional first-year interest

PLUS
– Any person who knowingly and with intent to injure, defraud, or deceive any insurer files an application for insurance containing any materially false information at least $5,000 in your annuity to keep it in force.
or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. LA-Any person • No administration fees3
who knowingly presents false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of Payment Options1 – There is no Withdrawal Charge if you elect a • Partial withdrawal provisions
a crime and may be subject to fines and confinement in prison. NJ – Notice: Any person who includes any false or misleading information on an application for formal Payment Option after five years. Your annuity offers a num- • 403(b)/457(b) loan rider
an insurance policy is subject to criminal and civil penalties. AR/NM/PA – Warning: Any person who knowingly and with intent to defraud any insurance company ber of formal Payment Options including: • Annual account statement
or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. VA • Nursing Care Rider (in states where approved) at no additional
– Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or • Installment Income – This is an ideal choice if you want to cost to you
deceptive statement may have violated state law. Notice to Residents of AZ: The annuity to which this application is attached may be returned within 31 days after receive your money over a fixed period of 10 to 25 years.
it is received. Return it to our Home Office or to the agent through whom it was purchased. If returned, we will cancel the annuity and return any premium paid. • Life Income Options – You cannot outlive your income. LSW Annuity Provisions
Upon written request from the Owner, we will provide within a reasonable time, factual information regarding the benefits and provisions of the annuity to which this

LSW’s
will continue to pay you as long as you live. If you elect a joint • Minimum premium: $5,000
application is attached. life option, LSW will pay you or your surviving spouse as long • Maximum premium: Issue Ages 0-75 $1,000,000. Issue Ages
as either of you are living. These choices can even be combined 76-80 $500,0004
SECTION X - Acknowledgments with a guaranteed minimum number of years for payment.

Single Premium
S1003 • Issue age: Annuitant/Owner – up to age 80 (actual age);
The Annuitant and the Owner, if other than the Annuitant; (1) represents, to the best of their knowledge and belief, that all statements and answers contained herein Individual Owner and Annuitant must be the same person
are full, complete and true as written and are correctly recorded; and, (2) expressly agrees as follows: Nursing Care Rider2 • Plan Options: Qualified and Non-qualified
LSW’s RetireMax® Millennium Plus includes a Nursing Care
Deferred Annuity Series
1. This application and the answers and agreements contained herein shall be the basis of, a part of the consideration for and a part of the annuity hereby applied for. • Withdrawal Charges waived on the death of the Annuitant
2. The payment of premium constitutes consideration to the Company for the granting of an annuity and upon payment becomes the absolute property of the Company. Rider that will eliminate Withdrawal Charges for policyowners who • This Policy is not contestable
3. If proof of age is not given with this application, the Annuitant(s) will furnish the Company with such proof before annuity payments begin. require long term care if: • A Withdrawal Charge may apply on amounts withdrawn in excess
4. The annuity applied for shall take effect on the date the premium is received by the Company in its Home Office. The SecurePlus single premium deferred annuities of free withdrawal
• the owner (under age 76 on the issue date of the Policy) stays
shall take effect on the 7th, 14th, 21st or 28th of the month following or coincident with the date the premium is received by the Company in its Home Office.
in a hospital and/or professional long term care facility for 60
5. The Company is authorized to amend this application by an appropriate notation in the space designated “For Home Office Endorsement Only” in order to Withdrawal Charges
days or longer. Withdrawal requests and documentation must
correct apparent errors or omissions. The acceptance of any annuity issued on this application shall constitute acceptance and ratification of the beneficiary be filed no later than 60 days after the end of the stay;
designation, if any, in such annuity and of any amendments contemplated above except that no change shall be made in the plan of annuity or benefits without Policy Year 1 2 3 4 5 6 7 8 9 10 11+
the written acceptance of the Annuitant(s) or of the Owner if other than the Annuitant(s).
• the policy has been in force longer than one year when the
Withdrawal
owner’s hospital and/or long term care stay begins;
W9: Under the penalties of perjury, I certify that: (1) the number shown on this application is my correct taxpayer identification number; (2) the IRS has never Charge 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0%
• the maximum aggregate withdrawal for all of the owner’s
notified me that I am subject to backup withholding, or has notified me that I am no longer subject to such withholding or I am exempt from such withholding; and
(3) I am a U.S. person (including a U.S. resident alien). You must cross out item 2 if you have been notified by the IRS that you are currently subject to backup
policies with this benefit does not exceed $250,000.
1 Benefits at annuitization could be reduced if a misstatement of age or sex
withholding because of underreporting interest or dividends on your tax return. has occurred.
If the owner is 76 or older on the issue date of the Policy, all of the
above provisions will apply. However, the waiver of Withdrawal 2 Nursing Care Rider not available in IL, LA, MA, MT, NH, NJ, PA, SC, WA,
WV, WI. Restrictions and additional conditions apply, refer to Rider Form
SECTION XI - Signature and Agent Information S1101 Charges will apply to a maximum of 25% of the Accumulation No. 7648.
Value with only one withdrawal allowed.
Dated at (city/state)___________________________________on (month/day/year)___________________________________________________ 3 A few states require the payment of premium taxes on annuities either at the
time the Company receives the premium, upon annuitization or withdrawal.
Life Insurance Company of the Southwest
Signature of Owner_ __________________________________Signature of Annuitant (if different from Owner)________________________________ If LSW must pay such taxes, we will deduct them from the Policy benefits. A Member of the National Life Group®
Signature of Joint Owner (if applicable)______________________________________ 4 Subject to change without notice.
To the best of my knowledge, a replacement________________ is is not involved in this transaction. (Agent to check box.) Florida License ID No._ _________ Note: There are special rules for annuities owned by trusts, corporate entities or
Signature of Agent_ _____________________________ Soliciting Agent (print)_ _______________________ Agent No.______________ Percent______
Form No. 9386 (1106)
qualified plans.
RetireMax Millennium Plus is Policy Form No. 7885. Loans are provided to
Protecting Your Retirement Savings
Agent Phone Number____________________________ Other Agent (print)___________________________ Agent No.______________ Percent______ Cat. No. 100718 403(b) and 457 policies by endorsement in states where approved.