[Logo of American PURCHASER SUITABILITY FORM EXHIBIT 99.B10
National appears here] & ARBITRATION AGREEMENT
This form must accompany all applications for American
National Variable Universal Life and Variable Annuity
products.
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1. NEW PURCHASER INFORMATION
Name_________________________________________ Date_____________________
Address________________________________________________________________
Social Security or Tax I.D. Number_____________________________________
If Purchaser is a corporation, partnership or other legal entity, names of any
persons authorized to transact business on behalf of entity:
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2. PURCHASER'S OCCUPATION
Name and Address of Employer___________________________________________
Business Phone_________________________________________________________
3. IS THE PURCHASER EMPLOYED BY OR ASSOCIATED WITH A MEMBER OF THE NASD OR NYSE?
[ ] Yes [ ] No If yes, provide the name, address and phone number
of the firm:________________________________________
____________________________________________________
4. TAX STATUS
[ ] Single [ ] Head of Household [ ] Married filing separate returns
[ ] Married filing joint return or qualifying widow(er) with dependent child
[ ] Corporation [ ] Other_____________________________________________
5. MARITAL STATUS
[ ] Married [ ] Single [ ] Widowed
6. DEPENDENTS
[ ] Spouse [ ] Children: Ages____________ [ ] Other_______________
INVESTOR SUITABILITY INFORMATION (the information requested applies to the
Applicant/Policy Owner if different from the Proposed Insured)
To be completed by Purchaser or Registered Representative.
NASD rules require Registered Representatives to have reasonable grounds for
believing the recommended purchase is suitable for the customer. Therefore,
representatives are required to make inquiries concerning the financial
condition of a proposed purchaser of any of American National's Variable
products. You are urged to supply such information so that the representative
can make an informed judgment as to the suitability of your investment
selection(s). However, you are not required to divulge such information. If you
choose not to do so, you must sign at the section provided below indicating
refusal and acknowledging that the representative did request the suitability
information.
1. SOURCES OF FUNDS FOR INVESTMENT
A. [ ] Current Earnings C. [ ] Gift or Inheritance E. [ ] Insurance Benefit
B. [ ] Savings D. [ ] Sale of Assets F. [ ] Maturity Proceeds G. [ ] ______________________
2. PRIMARY PURPOSE OF INVESTMENT
A. [ ] Education C. [ ] Savings E. [ ] Retirement G. [ ] Estate Planning
B. [ ] Tax Shelter D. [ ] Business Purposes F. [ ] Current Income H. [ ] ______________________
3. INVESTMENT PROFILE
(a) What is your current investment preference?
[ ] Aggressive Growth [ ] Growth [ ] Growth & Current Income
[ ] Current Income [ ] Maximum safety, even if modest return
(b) What is your risk comfort level?
[ ] High [ ] High/Moderate [ ] Moderate [ ] Moderate/Limited [ ] Low
(c) What is your financial goal time horizon?
[ ] 1-5 years [ ] 5-10 years [ ] 10 years and beyond
(d) What is your age range?
[ ] 21-40 [ ] 41-59 [ ] 60 +
(e) What is your tax bracket?
[ ] 15% [ ] 28% [ ] 28% +
(f) What is your estimated annual family income?
[ ] less than $15,000 [ ] $15,000-$30,000 [ ] $30,000-$50,000
[ ] $50,000-$100,000 [ ] Over $100,000
(g) What is your estimated net worth (exclude home, furnishings and automobiles)?
[ ] less than $25,000 [ ] $25,000 - $50,000 [ ] $50,000 - $100,000 [ ] Over $100,000
(h) Are you responsible for the financial welfare of anyone other than your immediate family (i.e. alimony, child or parental
support,etc.)? [ ] Yes [ ] No
(i) Do you own other securities? [ ] Yes [ ] No
Types: [ ] Stocks [ ] Bonds [ ] Mutual Funds [ ] Variable Products [ ] Other
I (we) furnished the above suitability information and it has been accurately recorded.
_________________________________________________________________ __________________________________________________________
Purchaser Signature Joint Owner Signature
continued on reverse side
STATEMENT OF REFUSAL TO PROVIDE FINANCIAL INFORMATION
I (we) fully understand that the Registered Representative, acting on behalf of
American National Insurance Company and Securities Management & Research, Inc.,
has requested the above suitability information to determine whether my (our)
purchase of American National's Variable products is an appropriate investment
considering my (our) financial situation. I (we) refuse to provide the requested
information and by my (our) signature(s) below agree not to seek rescission of
the applicable variable product issued or damages based on its unsuitability.
_____________________________________ __________________________________
Purchaser Signature Joint Owner Signature
REGISTERED REPRESENTATIVE NOTICE - Should the Purchaser sign the above Statement
of Refusal to Provide Financial Information, it is still an NASD requirement
that you have reasonable grounds to recommend the purchase of this investment as
suitable. Therefore, you must complete the suitability information to the best
of your knowledge and certify that you have done so when signing the Registered
Representative's Statement below.
PURCHASER AGREEMENT TO ARBITRATION
(THIS SECTION IS NOT APPLICABLE TO MISSOURI RESIDENTS)
The following conditions are agreed to by all parties to this agreement.
1. Arbitration is final and binding on the parties.
2. The parties are waiving their right to seek remedies in court, including the
right to a jury trial.
3. Pre-arbitration discovery is generally more limited and different from court
proceedings.
4. The arbitrators' award is not required to include factual findings or legal
reasoning and any party's right to appeal or to seek modification of rulings
by arbitrators is strictly limited.
5. The panel of arbitrators will typically include a minority of arbitrators who
were or are affiliated with the securities industry.
By signature below, I (we) understand that I (we) have the right to any dispute
between us arising under the federal securities laws to be resolved through
litigation in the courts. In lieu of using the courts, I (we) may agree, after
any such dispute has arisen, to settle it by arbitration before an appropriate
group of arbitrators. However, I (we) understand that any other dispute between
us arising out of any transaction or this agreement shall be settled by
arbitration before the National Association of Securities Dealer, Inc., which
must be commenced by a written notice of intent to arbitrate. Judgment upon any
award may be entered in any appropriate court.
I (we) further understand that we may not bring a punitive or certified class
action to arbitration, nor seek to enforce any pre-dispute arbitration agreement
against anyone who has initiated in court a punitive class action; or who is a
member of a punitive class action until (1) the class action certification is
denied; or (2) the class is decertified; or (3) I (we) are excluded from the
class action by the court. Such forbearance to enforce an agreement to arbitrate
shall not constitute a waiver of any right under this agreement except to the
extent stated herein.
_____________________________________ __________________________________
Purchaser Signature Joint Owner Signature
REGISTERED REPRESENTATIVE STATEMENT & SIGNATURE
Check appropriate boxes.
[ ] Application attached.
[ ] Signed Arbitration Agreement
[ ] Suitability Information was provided by the Purchaser(s) and the
Purchaser(s) signed acknowledgment that information was accurately
recorded.
or,
[ ] Refusal to Provide Financial Information Statement signed by
Xxxxxxxxx(s). I provided the suitability information to the best of my
knowledge and have reasonable grounds to recommend the purchase of this
investment as suitable for the Investor.
___________________________________ _______________________________________
Registered Representative Signature Registered Representative Personal Code
___________________________________ _______________________________________
Registered Representative Name (print) Date Branch Office # PSO#
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Home Office Approval:_____________________________________________________
Date Received:____________________________________________________________
