Preview
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
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81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
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PACIFIC LIFE
I, Trisha Hitchler, hereby affirm that the attached reproduction of the Contract for
Grayson J Osborne issued by Pacific Life is a true, correct, and complete copy of the
original document.
VHHEZm
Signature
DESCRIPTION OF THE ATTACHED DOCUMENT
Pacific Life Individual Single Premium Settlement Annuity Contract
Reference Number: -
CAPACITY CLAIMED BY THE SIGNER
Manager, Structured Settlement Services, Pacific Life
Pacific Life refers to Pacific Life Insurance Company and its affiliates, including Pacific Life & Annuity Company.
Insurance products are issued by Pacitic Life Insurance Company in all states except New York and in New York by
Pacific Life & Annuity Company. Product availability and features may vary by state. Each company is solely
rider guarantees
responsible for the financial obligations accming under the products it issues. Insurance product and
arc backed by the financial strength and claims-paying ability of the issuing company.
Pacific Life
Structured Settlement Annuities
700 Newport Center Drive. Newport Beach. California 926606397 Tel (888) 728-5611. Fax (402) 479-0102
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
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81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
COPY
Pacific Life Insurance Company
700 Center Drive
rt eac h. CA 9266 o
Newgort
N EWPO
PACIFIC LlFE 1-888-728-561 1
INDIVIDUAL SINGLE PREMIUM SETTLEMENT ANNUITY CONTRACT
Annuity Payments to be Made to Owner's Designee
Pacific Life Insurance Company, a stock company, ("Pacific Life") will pay annuity payments to
the contract Owner, or such person(s) as the contract Owner may designate, subject to the
provisions of this and the following pages which are made a part of this contract, according to
the attached Contract Data page(s).
READ YOUR CONTRACT CAREFULLY. This contract is a legal contract between the contract
Owner and Pacific Life. Pacific Life is a stockholder owned company. As such. purchasing and
owning a Pacific Life contract does not confer any membership rights nor ownership rights in
Pacific Life or any other company affiliated with Pacific Life.
Free Look Right-At any time within days after you receive this contract, you may return
1O it
to us or the brokerthrough whom you bought it. We will refund any premium paid less any
annuity payments made.
This Contract is issued in consideration of the application and payment of premium.
This contract is executed for Pacific Life at Newport Beach, California, to be effective as of the
Contract Date.
PACIFIC LIFE INSURANCE COMPANY
WW
President and Chief Executive Officer Secretary
Single Premium Settlement Annuity
Immediate Annuity No Cash Value
Non-Participating No Annual Dividends
-
Annuity Payments Specified in Contract Data
Annuities Payable in Fixed Dollar Amounts
lCC11:101213 09.11
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
f. g
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
TABLE OF CONTENTS
CONTRACT DATA 1
GENERAL PROVISIONS 2-3
ICC1 1:10-1213 09-11
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
CQPY
CONTRACT DATA
Contract Number- Contract Date: November 21, 2023
Owner: PACIFIC LIFE & ANNUITY SERVICES, INC.
SCHEDULE OF BENEFITS
Measuring Life: GRAYSON J OSBORNE
Payee Name: Please see Application.)
ContractICertificate No.:
Benefits paid:
(Please see Application.)
END
NO BENEFITS. INCLUDING ANY DEATH BENEFITS. ARE PAYABLE EXCEP'I' ON THE DATES AND
IN THE AMOUNTS SET FORTH ABOVE.
SERVICE CENTER
Send Forms and written requests to:
Pacific Life Insurance Company
P 0 Box 84307
Lincoln, NE 68501
Hours: Between 5:30 am and 2:00 pm. Pacific Standard Time.
Toll-Free Number for Contract Owners: 1-888-728-5611
Please use our toll-free number to present inquiries or obtain information about your coverage and for us
to provide assistance in resolving complaints or you may sell your state insurance department at
1-800-726-7390.
Page 1
lCCiizio-1213 09-11
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
l" I
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
81-CV-23-581
Filed in District Court
State of Minnesota
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12/12/2023 8:50 AM
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81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
81-CV-23-581
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Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
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81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
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Pacific Life Insurance Com an Individual Single
PACIFIC LIFE 700 Newport Center Drive. Newport Beach. A92 60 Premium Settlement
- - -
www.PacificLife.com
(877) 7mm
AnnUIty Application
1. MEASURING LIFE 1 Must be an individual.
Name (First. Middle, Last) Birth Date ProofofAge required)
Grayson James Osborne fixM BF
Mailin Address Ci State ZIP SN
Residential Address (if different than mailing address) City, State. ZIP Phone Number
MEASURING LIFE 2 Complete only if there is more than one Measuring Life.
Name (First, Middle. Last) Birth Dale (Proof of Age required)
fixM D F
City, State, ZIP SSN
Mailing Address
Residential Address (if different than mailing address) City, State. ZIP Phone Number
MEASURING LIFE 3 Complete only if there is more than two Measuring Lives.
Name (First. Middle, Last) Birth Date (Proof of Age required)
SSN
fl M DF
Mailing Address City, State, ZIP
Residential Address (irdifierenl than mailing address) City, State, ZIP Phone Number
2. OWNER: Owner is: Corporation D Trustee D Partnership D Individual
Name: TIN or SSN if individual)
Pacific Life & Annuity Services, Inc.
Mailing Address City, Slate, ZIP
Refer all inquiries to: 700 Newport Center Drive Newport Beach CA 92660
Street Address (if different than mailing address) City, State, ZIP
3. ANNUITY PLAN AND SCHEDULE OF PAYMENTS.
(blank area for description of annuity plan to be placed here and beneficiaries if applicable, or for language referring Addendum)
to
Please refer to Addendum No. 1 for Schedule of Benefits and Payees.
4. RIDERS: DBenetits Commutation D IRS Sec. 72ts) D Elimination of Liability D Marriage D index-LinkedBAnnttliity
ene t
Payment
Adjustment
The above riders will to the Plan and Schedule or Benefits and Payees as stated in Section 3 above or on the Addendum.
apply only Annuity
5. AMOUNT PAID WITH APPLICATION: Make check pa ble to Pacific Life & Annulty Services. Inc.
s Valuable Consideration
CONTINUED ON NEXT PAGE
ic¢14:25-1213-14 Page 1 or 2 toe-14]
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
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81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
6. STATEMENT OF OWN ER: This application will be part of the annuity contract issued by Pacific Life Insurance Company.
it is agreed that: (1) This application she! be the basis for any annuity contract issued; (2) Any annuity contract issued she! not take effect until the
contract is delivered to the owner and the single premium has been paid in full; (3) No information acquired by any representative of Pacific Life shall
be binding upon Pacific Life unless set out in writing in this application: and (4) No waiver or modification shalt be hinting upon Pacific Lite unless in
writing and signed by two authorized officers of Pacific Life. acting together.
I understand that federal law requires all financial institutions to obtain the name. residential address. date of birth. Social Security or taxpayer
identification number, and any other information necessary to sufiicientiy verify the identity of each customer. All answers to questions and
statements made on this application are to the best of my knowledge and belief. Any person who knowingly presents a false shtement in an
application for insulates may be guity ofa criminal chance and subject to penalties under state law.
Under penalties of perjury, I certify that: (1) the number shown on this form is my correct taxpayer identification number: and
(2) I am not an act to backup withholding because: (a) lam exempt from backup withholding, or (b) l have not been notified
by the Rs that am subject to backup withholding as a result of a failure to report all Interest or dividends, or (c) the IRS has
notified me thatl am no longer subject to backup withholding; and (3) i am a u.s. person (including a 0.8. resident alien); and
(4) I am exempt from Foreign Account Tax Compliance Act (FATCA) reporting. Cross out item 2 above if you have been
notified by the RS that you are currently subject to backup withholding because you have failed to report all interest and
dividends on your tax retum. NOTE: The IRS does not require my consent to any provision on this application other than the
certification required to avoid backup withholding.
Owner's Signatme Date (m/day/yr) Signed at City. State
SalrrmMwrtfivte/g 11/16/2023 Riverside, CA.
tSi Print Licensed Producer's Full Name
4m Joseph W. Loseman
ICC14:25-1213-14 Page 2 of 2 [06-14]
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
Addendum No. 1
Schedule of Benefits and Payees
Vie s u fin g Grayson James Osborne
Lift? Payee: Gravsonlamcs Osborne
Address:
I. Period Certain Annuity $2,500.00 payable annually, guaranteed for 6 year(s), beginning on 03/ l 1/2033, with
-
the last guaranteed payment on 03/ l 1/2038.
2. Guaranteed Lump Sum -
$76,352.15 paid as a lump sum on 03/11/2039 guaranteed.
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
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81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
PACIFIC LIFE
Pacific Life Insurance Company O 700 Newpott Center Drive 0 Newport Beach. CA 92660
SINGLE PREMIUM SETTLEMENT ANNUITY CONTRACT
Single Premium Settlement Annuity
Immediate Annuity No Cash Value
-
Non-Participating No Annual Dividends
Annuity Payments Specified in Contract Data
NOTICE: PACIFIC LIFE IS AN EQUAL OPPORTUNITYIAFFIRMATIVE ACTION EMPLOYER
Pacific Life is an Equal Opportunity and Affirmative Action Employer and agrees to comply with all the
provisions contained in Executive Order No. 11246, including specifically the Equal Employment
Opportunity clause in Section 202, the Vietnam Era Veteran's Readjustment Assistance Act of 1974.
Section 503 of the Rehabilitation Act of 1973, 29 U.S.C. 793. and implementing rules and regulations 41
CFR 60-1 .4, 41 CFR 60-2505 and 41 CFR 60-741.5(a), all amended and revised and hereby
incorporated herein by specific reference, as though fully set forth herein.
ICC11Z10-1213 09-11
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
81-CV-23-581
Filed in District Court
State of Minnesota
.(T'
12/12/2023
m.
8:50 AM
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81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
To learn more about the above protections, as well as protections relating to group contracts or
retirement plans, please visit the Association's website at www.mo-iga.org. or contact:
Missouri Life and Health Missouri Department of Commerce
Insurance Guaranty Association and Insurance
2210 Missouri Boulevard 301 West High Street, Room 530
Jefferson City. Missouri 65109 Jefferson City, Missouri 65101
Phone: 573-634-8455 Phone: 573-522-6] l5
Fax: 573-634-8488
Insurance companies and agents are not allowed by Missouri law to use the existence of the
Association or its coverage to encourage you to purchase any form of insurance or HMO coverage.
When selecting an insurance company, you should not rely on Association coverage. If there is any
inconsistency between this notice and Missouri law, then Missouri law will control.
MO-l
45-163M0 2 SSA -
12/20
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
81-CV-23-581
Filed in District Court
"a
'1
State of Minnesota
12/12/2023 8:50 AM
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81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
Schedule 1
Periodic Payments
Payee (1): n Osborne
Beneflt(s): $2,500.00 annually for six (6) years guaranteed. commencing 3/11/2033. with the last guaranteed payment on
3/1 1/2038; and
$76,352.15 guaranteed lump sum payment on 3/11/2039.
PLQA Page 4 of 5 m3
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
This Qualified Assignment Agreement is signed in one or more counterparts as of the Effective Date by the
following:
Assignor (1): Austin Mutual Insurance Company
uJiL.-..;isl.~fi':3:3 1r: 5; {D1'
By:
Authorized Representative(s)
EC Complex Claim Adjuster
Title
Assignee: Pacific Life & Annuitv Services. Inc. Assignee: Pacific Life 8. Annuity»Servico_s.fi1_§_.
3y; "firs/a
Authorized Representative
Mia/w By: C£/;\&'H CV"? 0/34
Autnonzefi Representative
Title: Manager Title: Supervisor
PLQA v2023
Page5of5
81-CV-23-581
Filed in District Court
State of Minnesota
12/12/2023 8:50 AM
No
Statement of Irrevocable Guarantee
Claimant: GRAYSON J OSBORNE
Pacific LifeCorp (PLC). a stock holding company domiciled in the State of Delaware. hereby states and represents as
follows:
VWrereas, PLC has created Pacific Life
& Annuity Services, Inc. (PLASI), a wholly-owned subsidiary
domiciled in the State of Missouri, to act as assignee and third-party owner with respect to Qualified
Assignments as provided in Section 130(c) of the Internal Revenue Code;
Whereas, PLASI has entered into a Qualified Assignment in the above referenced case; and
Whereas, PLC guarantees all of the obligations of PLASI. including the above referenced obligation.
Now, therefore, PLC states that if PLASI shall fail to make any payment as assumed under said
Qualified Assignment, then PLC, by virtue of said guarantee of all of the obligations of PLASI, shall
make such payment as and when due.
This statement is executed and signed this -2151 day of November , 2023
Pacfic LifeCorp
Starla Yamauchi
Assistant Vice President and Corporate Secretary
Preview
81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM - . .3: . ~, '. \-_ ' '\' k- i . A ._._- , . I 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM W/ PACIFIC LIFE I, Trisha Hitchler, hereby affirm that the attached reproduction of the Contract for Grayson J Osborne issued by Pacific Life is a true, correct, and complete copy of the original document. VHHEZm Signature DESCRIPTION OF THE ATTACHED DOCUMENT Pacific Life Individual Single Premium Settlement Annuity Contract Reference Number: - CAPACITY CLAIMED BY THE SIGNER Manager, Structured Settlement Services, Pacific Life Pacific Life refers to Pacific Life Insurance Company and its affiliates, including Pacific Life & Annuity Company. Insurance products are issued by Pacitic Life Insurance Company in all states except New York and in New York by Pacific Life & Annuity Company. Product availability and features may vary by state. Each company is solely rider guarantees responsible for the financial obligations accming under the products it issues. Insurance product and arc backed by the financial strength and claims-paying ability of the issuing company. Pacific Life Structured Settlement Annuities 700 Newport Center Drive. Newport Beach. California 926606397 Tel (888) 728-5611. Fax (402) 479-0102 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM , ' , , \v. "T .' ' . . ' 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM COPY Pacific Life Insurance Company 700 Center Drive rt eac h. CA 9266 o Newgort N EWPO PACIFIC LlFE 1-888-728-561 1 INDIVIDUAL SINGLE PREMIUM SETTLEMENT ANNUITY CONTRACT Annuity Payments to be Made to Owner's Designee Pacific Life Insurance Company, a stock company, ("Pacific Life") will pay annuity payments to the contract Owner, or such person(s) as the contract Owner may designate, subject to the provisions of this and the following pages which are made a part of this contract, according to the attached Contract Data page(s). READ YOUR CONTRACT CAREFULLY. This contract is a legal contract between the contract Owner and Pacific Life. Pacific Life is a stockholder owned company. As such. purchasing and owning a Pacific Life contract does not confer any membership rights nor ownership rights in Pacific Life or any other company affiliated with Pacific Life. Free Look Right-At any time within days after you receive this contract, you may return 1O it to us or the brokerthrough whom you bought it. We will refund any premium paid less any annuity payments made. This Contract is issued in consideration of the application and payment of premium. This contract is executed for Pacific Life at Newport Beach, California, to be effective as of the Contract Date. PACIFIC LIFE INSURANCE COMPANY WW President and Chief Executive Officer Secretary Single Premium Settlement Annuity Immediate Annuity No Cash Value Non-Participating No Annual Dividends - Annuity Payments Specified in Contract Data Annuities Payable in Fixed Dollar Amounts lCC11:101213 09.11 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM f. g 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM TABLE OF CONTENTS CONTRACT DATA 1 GENERAL PROVISIONS 2-3 ICC1 1:10-1213 09-11 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM CQPY CONTRACT DATA Contract Number- Contract Date: November 21, 2023 Owner: PACIFIC LIFE & ANNUITY SERVICES, INC. SCHEDULE OF BENEFITS Measuring Life: GRAYSON J OSBORNE Payee Name: Please see Application.) ContractICertificate No.: Benefits paid: (Please see Application.) END NO BENEFITS. INCLUDING ANY DEATH BENEFITS. ARE PAYABLE EXCEP'I' ON THE DATES AND IN THE AMOUNTS SET FORTH ABOVE. SERVICE CENTER Send Forms and written requests to: Pacific Life Insurance Company P 0 Box 84307 Lincoln, NE 68501 Hours: Between 5:30 am and 2:00 pm. Pacific Standard Time. Toll-Free Number for Contract Owners: 1-888-728-5611 Please use our toll-free number to present inquiries or obtain information about your coverage and for us to provide assistance in resolving complaints or you may sell your state insurance department at 1-800-726-7390. Page 1 lCCiizio-1213 09-11 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM l" I 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM 81-CV-23-581 Filed in District Court State of Minnesota . 12/12/2023 8:50 AM 1- ' 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM 81-CV-23-581 o Filed in District Court State of Minnesota 12/12/2023 8:50 AM ... , ,- ."w'". '_ l n . ' 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM ' Pacific Life Insurance Com an Individual Single PACIFIC LIFE 700 Newport Center Drive. Newport Beach. A92 60 Premium Settlement - - - www.PacificLife.com (877) 7mm AnnUIty Application 1. MEASURING LIFE 1 Must be an individual. Name (First. Middle, Last) Birth Date ProofofAge required) Grayson James Osborne fixM BF Mailin Address Ci State ZIP SN Residential Address (if different than mailing address) City, State. ZIP Phone Number MEASURING LIFE 2 Complete only if there is more than one Measuring Life. Name (First, Middle. Last) Birth Dale (Proof of Age required) fixM D F City, State, ZIP SSN Mailing Address Residential Address (if different than mailing address) City, State. ZIP Phone Number MEASURING LIFE 3 Complete only if there is more than two Measuring Lives. Name (First. Middle, Last) Birth Date (Proof of Age required) SSN fl M DF Mailing Address City, State, ZIP Residential Address (irdifierenl than mailing address) City, State, ZIP Phone Number 2. OWNER: Owner is: Corporation D Trustee D Partnership D Individual Name: TIN or SSN if individual) Pacific Life & Annuity Services, Inc. Mailing Address City, Slate, ZIP Refer all inquiries to: 700 Newport Center Drive Newport Beach CA 92660 Street Address (if different than mailing address) City, State, ZIP 3. ANNUITY PLAN AND SCHEDULE OF PAYMENTS. (blank area for description of annuity plan to be placed here and beneficiaries if applicable, or for language referring Addendum) to Please refer to Addendum No. 1 for Schedule of Benefits and Payees. 4. RIDERS: DBenetits Commutation D IRS Sec. 72ts) D Elimination of Liability D Marriage D index-LinkedBAnnttliity ene t Payment Adjustment The above riders will to the Plan and Schedule or Benefits and Payees as stated in Section 3 above or on the Addendum. apply only Annuity 5. AMOUNT PAID WITH APPLICATION: Make check pa ble to Pacific Life & Annulty Services. Inc. s Valuable Consideration CONTINUED ON NEXT PAGE ic¢14:25-1213-14 Page 1 or 2 toe-14] 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM , _ .- _' I .1 a ' ., _ _,'- J 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM 6. STATEMENT OF OWN ER: This application will be part of the annuity contract issued by Pacific Life Insurance Company. it is agreed that: (1) This application she! be the basis for any annuity contract issued; (2) Any annuity contract issued she! not take effect until the contract is delivered to the owner and the single premium has been paid in full; (3) No information acquired by any representative of Pacific Life shall be binding upon Pacific Life unless set out in writing in this application: and (4) No waiver or modification shalt be hinting upon Pacific Lite unless in writing and signed by two authorized officers of Pacific Life. acting together. I understand that federal law requires all financial institutions to obtain the name. residential address. date of birth. Social Security or taxpayer identification number, and any other information necessary to sufiicientiy verify the identity of each customer. All answers to questions and statements made on this application are to the best of my knowledge and belief. Any person who knowingly presents a false shtement in an application for insulates may be guity ofa criminal chance and subject to penalties under state law. Under penalties of perjury, I certify that: (1) the number shown on this form is my correct taxpayer identification number: and (2) I am not an act to backup withholding because: (a) lam exempt from backup withholding, or (b) l have not been notified by the Rs that am subject to backup withholding as a result of a failure to report all Interest or dividends, or (c) the IRS has notified me thatl am no longer subject to backup withholding; and (3) i am a u.s. person (including a 0.8. resident alien); and (4) I am exempt from Foreign Account Tax Compliance Act (FATCA) reporting. Cross out item 2 above if you have been notified by the RS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax retum. NOTE: The IRS does not require my consent to any provision on this application other than the certification required to avoid backup withholding. Owner's Signatme Date (m/day/yr) Signed at City. State SalrrmMwrtfivte/g 11/16/2023 Riverside, CA. tSi Print Licensed Producer's Full Name 4m Joseph W. Loseman ICC14:25-1213-14 Page 2 of 2 [06-14] 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM Addendum No. 1 Schedule of Benefits and Payees Vie s u fin g Grayson James Osborne Lift? Payee: Gravsonlamcs Osborne Address: I. Period Certain Annuity $2,500.00 payable annually, guaranteed for 6 year(s), beginning on 03/ l 1/2033, with - the last guaranteed payment on 03/ l 1/2038. 2. Guaranteed Lump Sum - $76,352.15 paid as a lump sum on 03/11/2039 guaranteed. 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM ' ' =.. M' 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM PACIFIC LIFE Pacific Life Insurance Company O 700 Newpott Center Drive 0 Newport Beach. CA 92660 SINGLE PREMIUM SETTLEMENT ANNUITY CONTRACT Single Premium Settlement Annuity Immediate Annuity No Cash Value - Non-Participating No Annual Dividends Annuity Payments Specified in Contract Data NOTICE: PACIFIC LIFE IS AN EQUAL OPPORTUNITYIAFFIRMATIVE ACTION EMPLOYER Pacific Life is an Equal Opportunity and Affirmative Action Employer and agrees to comply with all the provisions contained in Executive Order No. 11246, including specifically the Equal Employment Opportunity clause in Section 202, the Vietnam Era Veteran's Readjustment Assistance Act of 1974. Section 503 of the Rehabilitation Act of 1973, 29 U.S.C. 793. and implementing rules and regulations 41 CFR 60-1 .4, 41 CFR 60-2505 and 41 CFR 60-741.5(a), all amended and revised and hereby incorporated herein by specific reference, as though fully set forth herein. ICC11Z10-1213 09-11 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM 81-CV-23-581 Filed in District Court State of Minnesota .(T' 12/12/2023 m. 8:50 AM \ 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM To learn more about the above protections, as well as protections relating to group contracts or retirement plans, please visit the Association's website at www.mo-iga.org. or contact: Missouri Life and Health Missouri Department of Commerce Insurance Guaranty Association and Insurance 2210 Missouri Boulevard 301 West High Street, Room 530 Jefferson City. Missouri 65109 Jefferson City, Missouri 65101 Phone: 573-634-8455 Phone: 573-522-6] l5 Fax: 573-634-8488 Insurance companies and agents are not allowed by Missouri law to use the existence of the Association or its coverage to encourage you to purchase any form of insurance or HMO coverage. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between this notice and Missouri law, then Missouri law will control. MO-l 45-163M0 2 SSA - 12/20 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM 81-CV-23-581 Filed in District Court "a '1 State of Minnesota 12/12/2023 8:50 AM . - ' r _ - w. ,' . . . v' I, . ' v. . ' 1 . ' - 4 ' ~ . ' , " -_ . L, . ' ._ , . ~ .v . .. . . , ' . ' . - ' . > ' 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM Schedule 1 Periodic Payments Payee (1): n Osborne Beneflt(s): $2,500.00 annually for six (6) years guaranteed. commencing 3/11/2033. with the last guaranteed payment on 3/1 1/2038; and $76,352.15 guaranteed lump sum payment on 3/11/2039. PLQA Page 4 of 5 m3 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM This Qualified Assignment Agreement is signed in one or more counterparts as of the Effective Date by the following: Assignor (1): Austin Mutual Insurance Company uJiL.-..;isl.~fi':3:3 1r: 5; {D1' By: Authorized Representative(s) EC Complex Claim Adjuster Title Assignee: Pacific Life & Annuitv Services. Inc. Assignee: Pacific Life 8. Annuity»Servico_s.fi1_§_. 3y; "firs/a Authorized Representative Mia/w By: C£/;\&'H CV"? 0/34 Autnonzefi Representative Title: Manager Title: Supervisor PLQA v2023 Page5of5 81-CV-23-581 Filed in District Court State of Minnesota 12/12/2023 8:50 AM No Statement of Irrevocable Guarantee Claimant: GRAYSON J OSBORNE Pacific LifeCorp (PLC). a stock holding company domiciled in the State of Delaware. hereby states and represents as follows: VWrereas, PLC has created Pacific Life & Annuity Services, Inc. (PLASI), a wholly-owned subsidiary domiciled in the State of Missouri, to act as assignee and third-party owner with respect to Qualified Assignments as provided in Section 130(c) of the Internal Revenue Code; Whereas, PLASI has entered into a Qualified Assignment in the above referenced case; and Whereas, PLC guarantees all of the obligations of PLASI. including the above referenced obligation. Now, therefore, PLC states that if PLASI shall fail to make any payment as assumed under said Qualified Assignment, then PLC, by virtue of said guarantee of all of the obligations of PLASI, shall make such payment as and when due. This statement is executed and signed this -2151 day of November , 2023 Pacfic LifeCorp Starla Yamauchi Assistant Vice President and Corporate Secretary