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Logo American Please Check One Group Annuity Application
Skandia Life X.X. Xxx 000 for Participant Group ID# 008-Navigator
Xxxxxxx, XX 00000-0000
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1. Participant(Applicant) 3. Annuitant(if other than Participant)
Name Name
Address Address
Sex Male Female Date of Birth Sex Male Female Date of Birth
Social Security/Tax I.D. No. 000-00-0000 Social Security/Tax I.D. No.
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2. Co-Participant(if applicable) 4. Contingent Annuitant(if applicable)
Name Name
Address Address
Sex Male Female Date of Birth Sex Male Female Date of Birth
Social Security/Tax I.D. No. Social Security/Tax I.D. No.
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5. Beneficiary Designation (The Participant reserves the right to change the Beneficiaries unless indicated in No. 11.)
Primary Beneficiary Contingent Beneficiary
Name Relationship to Participant Name Relationship to Participant
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6. Initial Premium -------------------------------------------------------------------
$ 9. Type of Plan
Type of Payment X Check/Wire 1035 Exchange
Trustee-to-Trustee Transfer Non-qualified Qualified (indicate plan type):
XXX SEP/XXX XXX Rollover 401k 403b
Other
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7. Investment Selection 10. Replacement
(Indicate your investment allocation below. Please use Is this annuity intended to replace (in whole or in part)
only whole number percentages. They must total 100%.) an existing life insurance or annuity? Yes X No
Variable Investment Options (if applicable) (If yes, please indicate carrier, contract no. and
% approximate premium amount in No. 11)
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% 11. Special Instructions
% Allinace Navigator
%
Fixed Investment Options (if applicable)
YR % YR %
YR % YR %
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8. Amendments to the Application(Home office use only). 12. Statement of Additional Information
Yes. Please send me a statement of additional information.
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Agreement-I/We represent to the best of my/our knowledge and belief the
statements made in this application are true and complete; including, under
penalty of perjury, the Social Security or Tax ID numbers provided. It is
indicated and agreed that the only statements which are to be construed as the
basis of the contract are those contained in this application or in any
amendment to this application. I/WE HAVE ALSO RECEIVED A COPY OF THE PROSPECTUS
AND I/WE UNDERSTAND THAT: (A) ANNUITY PAYMENTS OR SURRENDER VALUES, WHEN BASED
ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT, ARE VARIABLE AND NOT
GUARANTEED AS TO A DOLLAR AMOUNT; AND (B) ALL PAYMENTS AND VALUES BASED ON THE
FIXED ACCOUNT ARE SUBJECT TO A MARKET VALUE ADJUSTMENT FORMULA, THE OPERATION OF
WHICH MAY RESULT IN EITHER AN UPWARD OR DOWNWARD ADJUSTMENT.
Signatures
Participant(s) X
Proposed Annuitant (if other than Participant) X
Dated at (location) Date
Signature of Agent X Agent Name (please print)
Name and Address of Firm
Agent Report
Do you have any reason to believe that the contract applied for is to replace
existing annuities or life insurance? Yes No
GPAA-12-94
