433-289(05-10) Page 1 of 3

All references to "the Company" shall mean Farm Bureau Life Insurance Company of Des Moines, Iowa.

VARIABLE UNIVERSAL LIFE - VARIABLE ANNUITY Insured/Annuitant Policy #

Owner’s Name Owner’s Address (Is this a change? Yes No)

I request the following service at applicable rates and rules currently in effect:

INVESTMENT OPTIONS A – FOR PRODUCTS WITH A POLICY DATE OF JUNE 2008 OR LATER

OPTION 1: Strategic Asset Allocation Model Portfolios – Select one model only.

2CN - Conservative 2MC - Moderate-Conservative 2MD - Moderate 2MA - Moderate-Aggressive 2AR - Aggressive

Election of one of the Strategic Asset Allocation Model Portfolios will result in funds being allocated or transferred in accordance with the model selection in effect on the date this request is received in the Home Office. The specific funds in the portfolio and the percentage allocations will be listed in the confirmation You receive from the Company. You understand that a Strategic Asset Allocation Model may change and that an updated model will automatically apply to your policy/contract unless you notify the company in writing or by calling 1-800-400-5742 that you decline the updated model.

If You selected a model above, do not enter percentages below.

OPTION 2: You may allocate your premium payments to a maximum of 12 investment options with the percentage allocated to each option being a whole percentage of at least 1% and the total of all percentage allocations equal to 100%. You may have money in up to 16 investment options, including the DIO, at any one time.

% SE3 - Calvert VP EAFE International Index - Class F % FG3 - Fidelity® VIP Growth - Service Class 2 % SN3 - Calvert VP Nasdaq -100 Index Portfolio % FH3 - Fidelity® VIP High Income - Service Class 2 % SR3 - Calvert VP Russell 2000 Index - Class F % FX3 - Fidelity® VIP Index 500 - Service Class 2 % SM3 - Calvert VP S&P MidCap 400 Index Portfolio - Class F % FM3 - Fidelity® VIP Mid Cap - Service Class 2 % CI3 - Columbia VIT International - Class A % FR3 - Fidelity® VIP Real Estate - Service Class 2 % CM3 - Columbia VIT Mid Cap Value - Class B % FV3 - Franklin Small Cap Value Securities Fund - Class 2 % CV3 - Columbia VIT Small Cap Value - Class B % FF3 - Franklin U.S. Government Fund - Class 2 % CG3 - Columbia VIT Small Company Growth - Class B % FT3 - Mutual Shares Securities Fund - Class 2 % WO3 - DWS Global Opportunities VIP - Class A % FI3 - Templeton Global Bond Securities Fund - Class 2 % WT3 - DWS Global Thematic VIP - Class A % JD3 - JPMorgan Insurance Trust Mid Cap Growth Portfolio % BC3 - EquiTrust VISF Blue Chip - Service Class % JG3 - JPMorgan Insurance Trust Intrepid Growth Portfolio % HQ3 - EquiTrust VISF High Grade Bond - Service Class % JM3 - JPMorgan Insurance Trust Intrepid Mid Cap % MG3 - EquiTrust VISF Managed - Service Class % JS3 - JPMorgan Insurance Trust Small Cap Core - Class 2 % MM3 - EquiTrust VISF Money Market - Service Class % TE3 - T. Rowe Price® Equity Income % HY3 - EquiTrust VISF Strategic Yield - Service Class % TI3 - T. Rowe Price® International Stock % GC3 - EquiTrust VISF Value Growth - Service Class % TN3 - T. Rowe Price® New America Growth % FC3 - Fidelity® VIP Contrafund® - Service Class 2 % TP3 - T. Rowe Price® Personal Strategy Balanced % DIO - Declared Interest Option (not available in all states)

VARIABLE POLICY SERVICE REQUEST

Farm Bureau Life Insurance Company 5400 University Avenue West Des Moines, Iowa 50266-5997

433-289(05-10) Page 2 of 3

INVESTMENT OPTIONS B – FOR PRODUCTS WITH A POLICY DATE PRIOR TO JUNE 2008

OPTION 1:

Strategic Asset Allocation Model Portfolios – Select one model only.

1MC –Moderate Conservative 1MD -Moderate 1MA –Moderate Aggressive 1AR -Aggressive

Election of one of the Strategic Asset Allocation Model Portfolios will result in funds being allocated in accordance with the model selection in effect on the date this request is received in the Home Office. The specific funds in the portfolio and the percentage allocations will be listed in the confirmation You receive from the Company. You understand that a Strategic Asset Allocation Model may change and that an updated model will automatically apply to your policy/contract unless you notify the company in writing or by calling 1-800-400-5742 that you decline the updated model.

If You selected a model above, do not enter percentages below.

OPTION 2: You may allocate your premium payments to a maximum of 12 investment options with the percentage allocated to each option being a whole percentage of at least 1% and the total of all percentage allocations equal to 100%. You may have money in up to 16 investment options, including the DIO, at any one time.

% ACB - American Century VP Inflation Protection Bond % FCF - Fidelity® VIP Contrafund®-Initial Class % ACF - American Century VP Value % FGR - Fidelity® VIP Growth-Initial Class % ACM - American Century VP Mid Cap Value % FGI - Fidelity® VIP Growth & Income-Initial Class % ACU - American Century VP Ultra® % FIX - Fidelity® VIP Index 500-Initial Class % ACV - American Century VP VistaSM % FMC - Fidelity® VIP Mid Cap-Service Class 2 % SM4 - Calvert VP S&P MidCap 400 Index Portfolio % FOS - Fidelity® VIP Overseas-Initial Class % SN1 - Calvert VP Nasdaq -100 Index Portfolio % FRE - Franklin Global Real Estate Securities Fund - Class 2 % SR2 - Calvert VP Russell 2000 Small Cap Index Portfolio % FTC - Franklin Small-Mid Cap Growth Securities Fund-Class 2 % DCA - Dreyfus VIF Appreciation % FTU - Franklin U.S. Government Fund - Class 2 % DGI - Dreyfus VIF Growth & Income % FTV - Franklin Small Cap Value Securities Fund - Class 2 % DIE - Dreyfus VIF International Equity % FTS - Mutual Shares Securities Fund - Class 2 % DSC - Dreyfus VIF Opportunistic Small Cap % FTG - Templeton Growth Securities Fund - Class 2 % DRG - Dreyfus Socially Responsible Growth Fund % JMV - JPMorgan Insurance Trust Mid Cap Value Portfolio % BC1 - EquiTrust VISF Blue Chip - Initial % JMC - JPMorgan Insurance Trust Small Cap Core Portfolio % HQ1 - EquiTrust VISF High Grade Bond - Initial % TEI - T. Rowe Price® Equity Income % HY1 - EquiTrust VISF Strategic Yield - Initial % TIS - T. Rowe Price® International Stock % MG1 - EquiTrust VISF Managed - Initial % TMC - T. Rowe Price® Mid-Cap Growth % MM1 - EquiTrust VISF Money Market - Initial % TNA - T. Rowe Price® New America Growth % GC1 - EquiTrust VISF Value Growth - Initial % TPS - T. Rowe Price® Personal Strategy Balanced % FH2 - Fidelity® VIP High Income-Service Class 2 % DIO - Declared Interest Option (not available in all states) CHANGE MY PREMIUM ALLOCATION - DOES NOT TRANSFER EXISTING VALUES To transfer existing values, complete the TRANSFER VALUES section below.

The net premium payments (as described in the Prospectus) are to be allocated to the appropriate subaccounts in the Investment Options section above.

CHANGE MY ALLOCATION OF CHARGES - FOR PRODUCTS WITH A POLICY DATE OF JUNE 2008 OR LATER DIO Option Money Market Option Pro Rata Option (This is the default)

TRANSFER VALUES - DOES NOT CHANGE PREMIUM ALLOCATION To change Premium Allocation, complete the CHANGE MY PREMIUM ALLOCATION section above.

Please note that Automatic Rebalancing, if applicable, is based on your then-current premium allocation.

Transfer current accumulated value to the subaccounts listed in the Investment Options section on Page 1, or

Transfer values as indicated below. Show percentage or dollar amount.

From $ or % To $ or %

$ or % $ or %

$ or % $ or %

$ or % $ or %

SPECIAL TRANSFER PRIVILEGE FOR VARIABLE UNIVERSAL LIFE Transfer the values in all subaccounts to the Declared Interest Option in accordance with the Special Transfer Privilege Provision of the

policy. I understand that as a result of my exercise of this special transfer privilege, the premium allocation of all future net premiums will be changed to the Declared Interest Option.

433-289(05-10) Page 3 of 3

SURRENDER REQUEST PARTIAL SURRENDER – Send check for $ . Values will be surrendered on a pro rata basis from my existing

subaccounts (as described in the Prospectus) or as specified below. SURRENDER FROM: SURRENDER FROM: $ or % $ or %

$ or % $ or %

$ or % $ or % • For Variable Annuity - Withdrawal may not be less than $500 and the remaining balance must be at least $2,000. • For Variable Universal Life - Withdrawal may not be less than $500 or more than 90% of the total cash value. If Death Benefit Option

B is in effect, the specified amount will be reduced but not less than the policy minimum and any Cost of Living Income Rider will be canceled.

FULL SURRENDER (Return policy with this form). Withdraw all cash value and terminate my policy. I understand if any net gain results from this transaction, Federal Income Tax will be due.

Such surrender shall not take effect until this form is received by the Company. When this form is received, the Company’s liability under the policy, except for payment of the net cash value, shall cease and terminate. In consideration of the payment of the net cash value, I acknowledge that all rights, claims, benefits, and demands under the policy are fully settled and satisfied. The Company is hereby released from any and all liability.

NET GAIN (IF ANY) FEDERAL INCOME TAX WITHHOLDING If neither box is checked, the Company is required to withhold for Federal Income Tax.

YES, I want withholding.

NO, I do not want withholding. If I elect not to have withholding apply to my distribution, or, if I do not have enough federal income tax withheld from this payment, I may be responsible for payment of estimated tax. I may incur penalties under estimated tax rules if my withholding and estimated tax payments are not sufficient.

I understand that I am subject to mandatory federal withholding of 20% on any funds eligible for rollover on any Keogh/Qualified or Tax Sheltered Annuity.

OTHER INSTRUCTIONS (BE SPECIFIC) Use PSR Form #433-279 for: • Change of Name • Policy loans • Ownership Change • Required Minimum Distribution • Lost Policy

The person signing this form declares that he or she has the legal right to assign, transfer or surrender the subject policy. Such person also declares that no bankruptcy proceedings are in process against the Insured, any Owner or Assignee. The changes requested on this form will not take effect until recorded at the Company. When recorded by the Company, the effective date of the change will be the date of this request without prejudice to the Company. I hereby request that any policy provision which requires submitting the policy for endorsement of the requested change be waived.

CERTIFICATION Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the

Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and

3. I am a U.S. person (including a U.S. resident alien). Certification instructions. You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, Item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN.

The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Unless the Company has been notified of a community property interest in this Policy, the Company shall be entitled to rely on its good faith belief that no such interest exists and assumes no responsibility for inquiry. The Owner and/or Insured signing this form agree to indemnify and hold the Company harmless from the consequences of accepting this transaction.

Date Owner SSN/Tax ID Agent _______ Owner

Other Required Signature