COLORADO BANKERS LIFE INSURANCE COMPANY BANKERS

COLORADO BANKERS LIFE INSURANCE COMPANY

BANKERS LIFE INSURANCE COMPANY

SOUTHLAND NATIONAL INSURANCE CORPORATION

HARDSHIP REQUEST FOR EXEMPTION FROM MORATORIUM

Updated March 23, 2022

We understand that certain policy owners may face financial hardships as a result of the court ordered

moratorium placed upon cash surrenders and partial withdrawals, under Colorado Bankers Life Insurance

Company, Bankers Life Insurance Company, and Southland National Insurance Corporation (“the Companies”)

policies or contracts. The Court has granted the Special Deputy Rehabilitator (the “Rehabilitator”) authority to

consider hardship payment requests. To request a hardship payment, you must complete and return the attached

“Hardship Request Form.” For the purpose of hardship requests, this form will replace the customary forms

that the Companies previously used for cash disbursement requests.

To qualify for hardship payment consideration, you must include the following:

 Notarized or Certified Statement of Facts that the Annuitant, Owner, or someone with a Power of

Attorney acting for the Owner or Annuitant has completed, made under the penalties of perjury. Briefly

describe the basis of the hardships, which must be based upon a proven financial need. This Statement of

Facts should list your income, liquid assets, and outline the circumstances that support your claim of

hardship and should accompany the information sent to our office. The hardship request will not be

processed unless the Statement of Facts is notarized (see exception below). If you deliver the enclosed

information by facsimile, then the Company must receive an identical, signed, and notarized original before

final approval may be granted. See the caution below about facsimile transmissions before sending

anything by facsimile. Please be as specific as possible, as the more information you give to the

Rehabilitator, the easier it will be to process your request.

 If you are unable to obtain a notarized statement due to restrictions in place from COVID-19, a

certified statement will be allowed. Please see Statement of Facts page.

 Proof or Evidence Supporting the Statement of Facts – This would include, as applicable, bills, notices,

doctor’s statements, or Power of Attorney, Guardianship or Conservator paperwork. List sources of income

for the policyholder and spouse, as applicable, including social security payments, salary and wages,

investment earnings (interest, dividends, etc.), retirement/pension, etc. Please provide copies of recent

paycheck stubs, Social Security Income receipts, etc. Provide the most recent asset balance page from third

party statements for policyowner and spouse, including but not limited to checking, savings, investment

accounts, and CDs.

[1] Please note that original documents will not be returned.

 Hardship Request Form

 Hardship criteria include but are not limited to:

[1] To prevent eviction or foreclosure on your principal residence - A hardship withdrawal may be

used to prevent eviction or foreclosure on your principal residence. Acceptable documentation

includes:

 Notice from the landlord or mortgage holder threatening eviction or foreclosure

 Amount needed to prevent such action

 Total amount owed

[2] Uninsured or unreimbursed medical expenses - A hardship withdrawal may be used for out-of-

pocket expenses for medical care. Acceptable documentation includes:

 Bills from doctors, hospitals, laboratories, and ambulance services

 Bills for prescriptions, eyeglasses, and medical supplies

 Documentation of amounts paid for medical insurance, as well as any amounts reimbursed

for medical expenses

 For ongoing medical treatment, a licensed physician’s statement estimating planned

treatment and associated costs

 Bills for home improvements strictly for medical reasons

[3] Post-secondary education expenses - A hardship withdrawal may be used to pay for up to 12

months of post-secondary expenses, tuition for yourself and/or your dependents, educational fees,

room and board, and supplies. Acceptable documentation includes:

 For tuition and educational fees: a copy of the bill on school letterhead or the school’s

online statement

 For books: proof of registration and a bill for book purchase

 For off-campus housing: proof of registration and a copy of the lease with landlord

information, monthly payment amounts, and length of lease

[4] Inability to pay for basic life support needs – A hardship may be used to pay for food, essential

utilities (i.e. gas, electricity, water, etc.), and shelter (i.e. mortgage, nursing home, etc.). Acceptable

documentation includes:

 List of significant expenses for the policyowner and spouse to sufficiently prove a financial

hardship (i.e. expenses exceed assets and/or income stream of policyowner and spouse, as

applicable). Copies of third-party statements/receipts are to be submitted

 A copy of a bill or invoice from utility company

 Notice from the landlord or mortgage holder threatening eviction or foreclosure

Assessment of the financial need by the Rehabilitator is based upon the proven existence of the hardship

(examples above) and adequate support of the financial need either currently or within the next 12 months. By

providing you with this information and these forms, we are not indicating whether the Rehabilitator will approve

your hardship request. The Rehabilitator will review each request on its own merits.

The Companies and the Rehabilitator are not responsible for undelivered mail. To protect the personal

information in your hardship request, the Rehabilitator recommends certified mail or some other delivery

service such as FedEx or UPS. Do not send anything by unsecured email.

In order to expedite the process, you can transmit the form via facsimile; however, the Companies and

the Rehabilitator shall not be responsible for any unintended disclosure or breach of such facsimile

transmission. If you choose to send it by fax, and accept responsibility for any unintended disclosure or

breach of such facsimile transmission, the fax number for Bankers Life is (727) 399-6965 and the fax

number for Colorado Bankers Life is: (303) 220-8056. The original forms must be received prior to final

approval.

Original Forms need to be mailed to one of the following addresses.

If using a delivery service such as FedEx or UPS:

Colorado Bankers Life

Insurance Company

C/O Actuarial Management

Resources

4964 University Parkway

Suite 203

Winston-Salem, NC 27106

Bankers Life Insurance

Company

C/O Actuarial Management

Resources

4964 University Parkway

Suite 203

Winston-Salem, NC 27106

Southland National

I

nsurance

Corporation

C/O Noble Consulting Services,

Inc.

211 N. Pennsylvania St

Suite 2350

Indianapolis, IN 46204

If using the U.S. Postal Service:

Colorado Bankers Life

Insurance Company

P.O. Box 11609

Winston-Salem, NC 27116

Bankers Life Insurance

Company

P.O. Box 11948

Winston-Salem, NC 27116

Southland National

I

nsurance

Corporation

P.O. Box 168

New Palestine IN 46163

Upon receipt of your completed hardship documents, the Rehabilitator will review them and reserves the right

to request additional information and documentation, as he deems appropriate. You must cooperate with the

Rehabilitator by providing all such requested documentation and information or your request will be denied.

If you have any questions, please contact the Companies by calling:

 For Colorado Bankers Life Insurance Company policies: 1-833-658-2841

 For Bankers Life Insurance Company policies: 1-833-658-2840

 For Southland National Insurance Corporation policies: 1-800-842-8960

Thank you in advance for your attention to these matters.

Michael Dinius

Special Deputy Rehabilitator

Hardship Application Checklist

Please make sure ALL requested documents are included in your submission. The Rehabilitator CANNOT

review an application until all documentation and forms have been received.

Please do not staple any documents.

 Hardship Request Form

Must be completed in its entirety, dated and signed by the owner, joint owner if applicable, and a witness.

 Certified Statement of Facts

A brief statement explaining your hardship. All pages of the statement MUST be notarized (see exception

on Statement of Facts page).

 Evidence of Liquid Assets

Copies of your most recent bank statements from ALL of your checking, savings and investment accounts.

 Evidence of Income

May include paystubs, award letters from Social Security, investment earnings statement, your prior year’s

professional tax return, or clearly indicate income on your bank statement.

 Proof of Your Monthly Expenses and/or Unpaid Bills

These documents must support the amount you are requesting, and you must provide the actual statements.

Monthly expenses would include rent/mortgage, water, electricity, gas, etc. Unpaid bills would include past

due accounts such as medical bills, loans, or tuition.