APPLICATION FORM Aetna Life Insurance and Annuity Company
Group Annuity Contracts 000 Xxxxxxxxxx Xxxxxx, Xxxxxxxx, XX 00000-
8022
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CLIENT 1. Name of applicant/employer
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INFORMATION 2. Address
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City State ZIP Code
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3. Tax Identification No.
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4. Name of plan (if any)
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ACCOUNT INFORMATION 5. Type of plan and section of Internal Revenue Code (if any) under which plan is to qualify:
|_| 403(b) Public School System |_| 457 Public Employer |_| Non-457 Tax-Exempt Deferred
Tax-Deferred Annuity Deferred Compensation Compensation (for select man-
agement and highly compensated
|_| 403(b) for 501(c)(3) Organization employees)
Tax-Deferred Annuity (Organizations formed after
10/9/69 must have IRS ruling regarding 501(c)(3) status) |_| 457 Tax-Exempt Deferred
|_|Retirement Plus |_| AHA Retirement Plus Compensation (for select man-
agement and highly compensated
employees)
|_| 401(k) for 501(c)(3) Organization (Organizations
formed after 10/9/69 must have IRS ruling regarding |_| Other____________________
501(c)(3) status)
|_| Optional Retirement Plan for Higher Education
|_| 403(b) |_| 401(a)
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6. Is this contract subject to ERISA Title I? |_| Yes If yes, Plan anniversary Month _____ Day _____
|_| No
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7. Contract is to be: |_| Allocated |_| Unallocated 8. Contract effective date
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9. GAA Maturity Notices should be mailed to: |_| Participants |_| Employer
|_| Participants and Employer
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10. Will this contract change or replace any existing life insurance or annuity contract? |_| Yes |_| No
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If yes, please provide carrier name, account number, and date to be canceled.
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11. Special Requests
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12. Participants may elect the investment allocation for:
INVESTMENT OPTIONS |_| Employer and Employee contributions |_| Employee contributions only |_| None Contract Holder elects
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13. For Employer directed allocations: Enter the percentage of payment and the investment option
chosen for allocation purposes.
|_| Employer Modal Contributions:____________________________________________________________________
|_| Employee Modal Contributions:____________________________________________________________________
|_| Transferred Assets:______________________________________________________________________________
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I understand that amounts withdrawn from a GAA Term may
be subject to a market value adjustment prior to the
maturity date of that Term as specified in the contract.
I further understand that Annuity payments and account
values, (if any), when based on the investment
experience of a separate account, are variable and not
guaranteed as to fixed dollar amount.
Dated at _________________________________ this
City and State
__________________ day of _______________ 19____.
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Witness
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Contract Holder
300-MOP-IB
Home Office Use: Accepted __________________
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PRODUCER'S NOTE: Do you have any reason to believe any existing life
insurance or annuity contract will be modified or
replaced if this contract is issued? |_| Yes |_| No
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Signature of Producer
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Corrections and amendments (Home Office Use Only).
Errors and omissions may be corrected by the Company but
no change in plan, classification, amount, age at issue,
or extra benefits shall be made without written consent
of the Contract Holder. (N/A in X.XX.)
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Affix Prospectus
Receipt Here
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