DA _____________
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Allianz Life Insurance Company of North America
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[Allianz Rewards(TM)]
Individual Flexible Payment Variable Deferred Annuity Application
Issued by Allianz Life Insurance Company of North America (Allianz Life),
Minneapolis, MN
Countrywide except NY
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1. ACCOUNT REGISTRATION
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Owner is Individual (must be age 80 or younger.)
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Individual Owner First Name Middle Initial Last Name (Jr or Sr), or III
Owner is __Trust __Qualified Plan __Custodian (If Trust, please include the date
of Trust in the name.)
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Non-Individual Owner Information
If Trust is Owner, please refer to Trustee Representation form.
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Tax ID number Social Security number
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Street Address
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City State ZIP Code Daytime telephone number
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Sex __M __F Date of Birth (mm/dd/yyyy)
Are you a U.S. Citizen? __Yes No__ If no, need W8-BEN.
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JOINT OWNER(Optional) (Must be the spouse of the Contract Owner except in the
states of CA, NJ, OR and PA.) (Must be age 80 or younger.)
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First Name Middle Initial Last Name (Jr or Sr), or III
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Street Address
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City State ZIP Code Daytime telephone number
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Sex __M __F Date of Birth (mm/dd/yyyy) Social Security number
Are you a U.S. Citizen? __Yes No__ If no, need W8-BEN.
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Relationship to Contract Owner
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ANNUITANT (Must complete if different than Contract Owner.) (Must be age 80 or
younger.)
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First Name Middle Initial Last Name (Jr or Sr), or III
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Street Address
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City State ZIP Code Daytime telephone number
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Sex __M __F Date of Birth (mm/dd/yyyy) Social Security number
Are you a U.S. Citizen? __Yes No__ If no, need W8-BEN.
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2. PURCHASE PAYMENT
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This section must be completed. Please make check payable to Allianz Life.
$15,000 minimum Purchase Payment required. If optional PRIME Plus Benefit is
selected, then $25,000 initial minimum Purchase Payment required.
____Purchase Payment enclosed with application
Purchase Payment amount $_______________________
____This contract will be funded by a 1035 exchange, Tax Qualified
Transfer/Rollover, CD Transfer or Mutual Fund Redemption.(If checked, please
include the appropriate forms.)
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3. PLAN SPECIFICS
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[This section must be completed to indicate how this contract should be issued.
NonQualified:__
Inherited IRA's: __IRA __Roth XXX __SEP XXX
Qualified IRA's: __IRA __Roth XXX __SEP XXX
__Roth Conversion New Xxxx or XXX contribution for tax year____
Qualified Plans: __403(b)(90-24 transfer)
__401
__401 One Person Defined Benefit]
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4. REPLACEMENT
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This section must be completed.
Do you have existing life insurance or annuity contracts? __YES* __No
If yes, will the annuity contract applied for replace or change existing
contracts or policies? __YES* __No
If yes, the Registered Representative must answer the replacement question in
section 11 of this application. *Please include the appropriate forms for NAIC
Model Regulation states.
F40327 (1-06)
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5. INCOME BENEFIT OPTION
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YOU MUST SELECT whether to receive the PRIME Plus Benefit or not. NOTE: If the
PRIME Plus Benefit is selected, then $25,000 initial minimum Purchase Payment is
required.
To receive the PRIME Plus Benefit you must check the following box:
__PRIME Plus Benefit (Available to owners age [79] or younger at time of
selection at additional cost.) BY SELECTING THE PRIME PLUS BENEFIT, I CONSENT
THAT ALLIANZ LIFE MAY REALLOCATE MY REWARDS VALUE IN ACCORDANCE WITH THE ASSET
ALLOCATION AND TRANSFER PROVISIONS IN THE CONTRACT.
If you do not want to receive the PRIME Plus Benefit you must check the
following box:
__No PRIME Plus Benefit (No additional cost.)
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6. DEATH BENEFIT OPTIONS
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You must choose only ONE of the following Death Benefit Options. Upon making
your selection, it cannot be changed.
__Traditional Guaranteed Minimum Death Benefit (No additional cost.)
__Enhanced Guaranteed Minimum Death Benefit (Optional) (Available to owners age
79 or younger on the Issue Date at additional cost.)
IF NO SELECTION IS MADE, THE TRADITIONAL GUARANTEED MINIMUM DEATH BENEFIT WILL
APPLY.
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7. PURCHASE PAYMENT ALLOCATION
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[COMPLETE THIS SECTION FOR ALLOCATIONS AND DOLLAR COST AVERAGING (DCA) SOURCE
INVESTMENT CHOICE. You may select up to 15 Investment Choices. Must use whole
percentages (33.3% or dollars are not permitted). Total of percentages in this
section must total 100%.
PLEASE NOTE: If DCA is being requested, DCA form must be attached to indicate
which Investment Choices you wish to dollar cost average into. If this form is
NOT attached and you request DCA, we cannot invest your Purchase Payement.
DCA FIXED OPTIONS (DCA Form must be attached.)
__% 12-Month DCA Fixed Option
__% 6-Month DCA Fixed Option
FUSIONPORTFOLIO
__% USAZ(R)Fusion Balanced
__% USAZ(R)Fusion Moderate
__% USAZ(R)Fusion Growth
SMALL CAP
__% Dreyfus Small Cap Stock Index
__% USAZ(R)Dreyfus Premier Small Cap Value
__% USAZ(R)Franklin Small Cap Value
__% USAZ(R)Xxxxxxxxxxx Emerging Growth
__% USAZ(R)Salomon Brothers Small Cap Growth
MID CAP
__% Franklin Rising Dividends Securities
__% Mutual Shares Securities
__% USAZ(R)OCC Renaissance
__% USAZ(R)Xxx Xxxxxx Aggressive Growth
__% USAZ(R)Xxx Xxxxxx Mid Cap Growth
__% Franklin Small - Mid Cap Growth Securities
LARGE GROWTH
__% Franklin Large Cap Growth Securities
__% USAZ(R)Dreyfus Founders Equity Growth
__% USAZ(R)Xxxxxxxx Growth
__% USAZ(R)Salomon Brothers Large Cap Growth
__% USAZ(R)Xxx Xxxxxx Emerging Growth
INTERNATIONAL EQUITY
__% Mutual Discovery Securities
__% Xxxxxxxxx Foreign Securities
__% Xxxxxxxxx Growth Securities
__% USAZ(R)AIM International Equity
__% USAZ(R)Xxxxxxxxxxx Global
__% USAZ(R)Xxxxxxxxxxx International Growth
__% USAZ(R)Xxx Xxxxxx Global Franchise
LARGE BLEND
__% Dreyfus Stock Index
__% Franklin Growth and Income Securities
__% USAZ(R)Xxxxxxxx 20/20 Focus
__% USAZ(R)Xxxxxxxxxxx Main Street
__% USAZ(R)Xxxx Xxxxx Value
LARGE VALUE
__% USAZ(R)AIM Basic Value
__% USAZ(R)Xxxxx NY Venture
__% USAZ(R)OCC Value
__% USAZ(R)Xxx Xxxxxx Xxxxxxxx
__% USAZ(R)Xxx Xxxxxx Growth and Income
HIGH YIELD BONDS
__% Franklin High Income
__% PIMCO VIT High Yield
INTERMEDIATE-TERM BONDS
__% Franklin Zero Coupon - 2010
__% PIMCO VIT Emerging Markets Bond Portfolio
__% PIMCO VIT Global Bond Portfolio
__% PIMCO VIT Real Return
__% PIMCO VIT Total Return
SHORT-TERM BONDS
__% Franklin U.S. Government
SPECIALTY
__% Xxxxx VA Financial
__% Franklin Global Communications Securities
__% Franklin Income Securities
__% Franklin Real Estate
__% PIMCO VIT All Asset Portfolio
__% PIMCO VIT Commodity Portfolio
__% Xxxxxxxxx Developing Markets Securities
__% USAZ(R)Xxxx Xxxxx Growth
__% USAZ(R)Xxxxxxxxxxx Emerging Technologies
__% USAZ(R)Xxx Xxxxxx Equity and Income
CASH EQUIVALENT
__% USAZ(R) Money Market
TOTAL of _____________________%
(Must equal 100%)]
[Flexible Reblancing Quarterly: You may select Flexible Rebalancing on a
QUARTERLY basis by checking this box __ if you have NOT selected any DCA Fixed
Options, or the Dollar Cost Averaging Program. Your Flexible Rebalancing will be
based on the same allocations as indicated above.
If you are requesting any other mode than quarterly for Flexible Rebalancing or
if you are selecting a Dollar Cost Averaging Program, please complete the
Flexible Rebalancing form and/or the Dollar Cost Averaging form.]
F40327 (1-06)
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8. TELEPHONE AUTHORIZATION
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___ Yes
By checking "yes," I am authorizing and directing Allianz Life to act on
telephone or electronic instructions from the registered representative
and/or anyone authorized by him/her to transfer Contract Values among the
Investment Choices. IF THE BOX IS NOT CHECKED, THIS AUTHORIZATION WILL BE
PERMITTED FOR THE OWNER ONLY. Allianz Life will use reasonable procedures
to confirm that these instructions are authorized as genuine. As long as
these procedures are followed, Allianz Life and its affiliates and their
directors, trustees, officers, employees, representatives, and/or agents
will be held harmless for any claim, liability, loss, or cost. The
electronic transaction privilege may be modified or withdrawn at the
discretion of the Company.
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9. BENEFICIARY DESIGNATION
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If the Beneficiary is a Trust, Qualified Plan or Custodian, please check the box
and include the name below __Trust __401 Qualified Plan __Custodian
__Primary __Contingent
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Percentage Tax ID number Social Security number
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Non-Individual Beneficiary Information (If Trust, please include date of Trust
in name.) (If owner is a 401 qualified plan, the plan must be the beneficiary.)
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__Primary __Contingent
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Percentage Tax ID number Social Security number
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First Name Middle Initial Last Name
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Relationship
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__Primary __Contingent
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Percentage Tax ID number Social Security number
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First Name Middle Initial Last Name
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Relationship
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__Primary __Contingent
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Percentage Tax ID number Social Security number
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First Name Middle Initial Last Name
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Relationship
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(If more than 4 beneficiaries, attach a list signed by Owner. At the Contract
Owner's death, the surviving Joint Owner becomes the Primary Beneficiary.)
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10. STATEMENT OF APPLICANT
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The following states require applicants to read and acknowledge the statement
for your state below.
[ARIZONA: Upon your written request, we will provide you with factual
information regarding the benefits and provisions of the Annuity Contract for
which you are applying. If for any reason you are not satisfied with the Annuity
Contract, you may return the Contract within 10 days after you receive it for a
full refund of the Contract Value. IF YOU ARE AGE 65 OR OLDER ON THE DATE OF THE
APPLICATION, YOU MAY RETURN THE CONTRACT WITHIN 30 DAYS AFTER YOU RECEIVE IT FOR
A FULL REFUND OF THE CONTRACT VALUE.
ARKANSAS, KENTUCKY, LOUISIANA, MAINE, NEW MEXICO, OHIO, TENNESSEE: Any person
who knowingly, and with intent to defraud any insurance company, submits an
application or files a statement of claim containing any false, incomplete, or
misleading information, commits a fraudulent insurance act, which is a crime,
may be subject to criminal prosecution and civil penalties. In ME and TN,
additional penalties may include imprisonment, fines, or a denial of insurance
benefits.
COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading
facts or information to an insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may include imprisonment, fines,
denial of insurance, and civil damages. Any insurance company or agent of an
insurance company who knowingly provides false, incomplete, or misleading facts
or information to a policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with regard to a settlement
or award payable from insurance proceeds shall be reported to the Colorado
division of insurance within the department of regulatory agencies.
DISTRICT OF COLUMBIA, PENNSYLVANIA AND VIRGINIA: Any person who knowingly and
with the intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false
information or conceals for the purpose of misleading, information concerning
any fact material thereto commits a fraudulent insurance act(except VA), which
is a crime and subjects such person to criminal and civil penalties. In DC and
VA, additional penalties may include imprisonment and/or fines, or denial of
insurance benefits.
FLORIDA: Any person who knowingly and with the intent to injure, defraud, or
deceive any insurer files a statement of claim or an application containing any
false, incomplete, or misleading information is guilty of a felony of the third
degree.
NEW JERSEY: Any person who includes any false or misleading information on an
application for an insurance policy is subject to criminal and civil penalties.
VERMONT: I understand that this variable annuity is not a bank deposit; is not
federally insured; is not endorsed by any bank or government agency; is not
guaranteed and may be subject to loss of principal.]
F40327 (1-06)
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10. STATEMENT OF APPLICANT (CONTINUED)
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By signing below, the Contract Owner acknowledges the statements mentioned above
and understands that or agrees to the following:
I received a Prospectus and have determined that the variable annuity applied
for is not unsuitable for my investment objectives, financial situation, and
financial needs. It is a long-term commitment to meet financial needs and goals.
I UNDERSTAND THAT THE CONTRACT VALUE AND VARIABLE ANNUITY PAYMENTS MAY INCREASE
OR DECREASE DEPENDING ON THE INVESTMENT RESULTS OF THE VARIABLE INVESTMENT
CHOICES, AND THAT NO MINIMUM CONTRACT VALUE OR VARIABLE ANNUITY PAYMENT IS
GUARANTEED. To the best of my knowledge and belief, all statements and answers
in this application are complete and true. It is further agreed that these
statements and answers will become a part of any contract to be issued. No
representative is authorized to modify this agreement or waive any of Allianz
Life's rights or requirements.
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Contract Owner's signature Joint Owner's signature
(or Trustee, if applicable) (or Trustee, if applicable)
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Signed at (city and state) Date signed __Please send me a Statement of
Additional Information also
available on the SEC web site
(xxxx://xxx.xxx.xxx).
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11. REGISTERED REPRESENTATIVE
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By signing below, the Registered Representative/Agent Certifies to the
following:
I am NASD registered and state licensed for variable annuity contracts in all
required jurisdictions; and I provided the Contract Owner(s) with the most
current Prospectus. To the best of my knowledge the applicant: ___DOES___DOES
NOT have existing life insurance policies or annuity contracts. To the best of
my knowledge and belief, this application ___DOES___DOES NOT involve replacement
of existing life insurance or annuities. If a replacement, include a copy of
each disclosure statement and a list of companies involved.
1. ______________________________________ [-------------
Registered Representative's signature B/D Rep ID
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Registered Representative's first and last name (please print) % Split
2. __________________________________________________ Registered ------------
Representative's signature (split case) B/D Rep ID
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Registered Representative's first (split case) % Split
and last name (please print)
3. __________________________________________________ Registered ------------
Representative's signature (split case) B/D Rep ID
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Registered Representative's first (split case) % Split]
and last name (please print)
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Registered Representative's telephone number
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Registered Representative's address
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Broker/dealer name (please print)
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Authorized signature of broker/dealer (if required)
[Representative's FLORIDA Insurance License Number
(complete if application signed in Florida) ___________________________________]
[Commission Options: (Please check one) __ A __ B __ C]
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12. HOME OFFICE USE ONLY
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If Allianz Life Insurance Company of North America makes a change in this space
in order to correct any apparent errors or omissions, it will be approved by
acceptance of this contract by the Owner(s); however, any material change must
be accepted in writing by the Owner(s). Changes to this application that affect
product, benefits, amount of insurance or age require acceptance by the
Owner(s).
[ MAILING INFORMATION
APPLICATIONS THAT HAVE A CHECK ATTACHED
REGULAR MAIL OVERNIGHT, CERTIFIED, OR REGISTERED
Allianz Life-Allianz Service Center Allianz Life-Allianz Service Center 824240
XX Xxx 000000 x/x XXX Xxxx Xxxxxxx
Xxxxxxxxxxxx, XX 00000-0000 Route 38 and Xxxx Xxxx Xxxxx
Xxxxxxxxxx, XX 00000
APPLICATIONS THAT DO NOT HAVE A CHECK ATTACHED
REGULAR MAIL OVERNIGHT, CERTIFIED, OR REGISTERED
Allianz Life-Allianz Service Center Allianz Life-Allianz Service Center
XX Xxx 0000 000 Xxxxxx Xxxx
Xxxxxxxxxxxx, XX 00000-0000 Xxxxxx, XX 00000-0000
For further questions, please call the Allianz Service Center at (800)
624-0197.]
F40327 (1-06)
