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Logo American Annuity Application
Skandia Life (Individual)
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1. Owner(Applicant) 3. Annuitant(if other than Owner)
Name Xxxx Xxx Name
Address 10 Any Street Address
Anytown, Anystate 12345
Sex X Male Female Date of Birth 03/29/47 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-Owner(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 Owner reserves the right to change the Beneficiaries unless indicated in No. 10.)
Primary Beneficiary Contingent Beneficiary
Name Xxxx Xxx Relationship to Owner Name Xxxxx Xxx Relationship to Owner
Wife Daughter
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6. Initial Premium -------------------------------------------------------------------
$ 50,000 9. Type of Plan
Type of Payment X Check/Wire 1035 Exchange -------------------------------------------------------------------
Trustee-to-Trustee Transfer X 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
X XX Money Market 100 % approximate premium amount in No. 11)
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% 11. Special Instructions
%
%
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
Owner(s) X /s/Xxxx Xxx
Proposed Annuitant (if other than Owner) X
Dated at (location) Anytown, Anystate Date 01/03/92
Signature of Agent X /s/ Xxxxxx Xxxxx Agent Name Xxxxxx Xxxxx
Name and Address of Firm XYZ Agency, 000 Xxxxx Xxxxxx, Xxxxxxx, Xxxxxxxx 00000
Agent Report
Do you have any reason to believe that the contract applied for is to replace
existing annuities or life insurance? Yes X No
INAA-2-92
