(5)(c) Application for the Glenbrook ____________ Variable Annuity Contract
GLENBROOK ________________ VARIABLE ANNUITY
(FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY)
Issued by: Glenbrook Life and Annuity Company
PO Box 94042, Palatine, Illinois 60094
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1. Owner(s)
Name ________________________________ // M // F Birthdate __/__/____
Address _____________________________ Soc. Sec. No. ____-____-____
Street
_____________________________________ Phone No. ( ) _____________
City State Zip
Name ________________________________ // M // F Birthdate __/__/____
Address _____________________________ Soc. Sec. No. ____-____-____
Street
_____________________________________ Relationship to Other Owner ___________
City State Zip
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2. Annuitant
Leave blank if Annuitant is the same as sole Owner, otherwise complete.
Name ________________________________ // M // F Birthdate __/__/____
Address _____________________________ Soc. Sec. No. ____-____-____
Street
_____________________________________
City State Zip
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3. Beneficary(ies)
Primary Contingent Name Relationship to Owner %
// // _________________________ _____________________ ___
// // _________________________ _____________________ ___
// // _________________________ _____________________ ___
// // _________________________ _____________________ ___
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4. Death Benefit Options
Choose one or any combination of the following:
Base Contract + // No Rider, or // Enhanced Death Benefit Rider, or
// Enhanced Earnings Death Benefit Rider; or // Income Benefit Rider
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5. Purchase Payment/Variable Account Plan Options
Initial Purchase Payment $ ___________
Please allocate the above amount in $ or % (circle one) to the Variable
Sub-Accounts specified below:
Total must equal 100%
AIM V.I. Funds Xxxxxxxx Xxxxxxxxx-Class 2 Funds Xxxxxx Xxxxxxx Asset Management
// Balanced Fund ___ // Franklin Small Cap Fund ___ // UIF Equity Growth Portfolio ___
// Diversified Income Fund ___ // Mutual Shares Securities ___ // UIF Fixed Income Portfolio ___
// Government Securities Fund ___ // Xxxxxxxxx Developing Markets // UIF Global Equity Portfolio ___
// Growth Fund ___ Securities ___ // UIF Mid Cap Value Portfolio ___
// Growth and Income Fund ___ // Xxxxxxxxx Growth Securities ___ // UIF Value Portfolio ___
// International Equity Fund ___ // Xxxxxxxxx International
// Value Fund ___ Securities ___ Xxxxxxxxxxx Funds
// Aggressive Growth Fund/VA ___
Dreyfus Xxxxxxx Xxxxx VIT // Capital Appreciation Fund/VA ___
// The Dreyfus Socially Responsible // Capital Growth Fund ___ // Global Securities Fund/VA ___
Growth Fund, Inc. ___ // CORE-SM- U.S. Equity Fund ___ // Main Street Growth and Income Fund/VA ___
// Stock Index Fund ___ // CORE-SM- Small Cap Equity Fund ___ // Strategic Bond Fund/VA ___
// VIF Growth & Income ___ // Global Income Fund ___
// VIF Money Market ___ // International Equity Fund ___
Fidelity MFS
// VIP Contrafund-R- ___ // Emerging Growth Series ___
// VIP Equity-Income ___ // Growth with Income Series ___
// VIP Growth ___ // New Discovery Series ___
// VIP High Income ___ // Research Series ___
DCA Fixed Account
(Subject to state availability) MVA Fixed Account (not available in GA, MD, OR, TX, WA)
// Short Term DCA ___ // 1 Year Guarantee Period ___ // 7 Year Guarantee Period ___
// Extended Short Term DCA ___ // 3 Year Guarantee Period ___ // 10 Year Guarantee Period ___
// 5 Year Guarantee Period ___
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6. Tax Qualified Plan
// Yes // No (If yes, complete the following.)
// Traditional IRA or // Xxxx XXX // SEP // Other _________
// Rollover // Transfer // Contribution $ ____ Contribution Year ____
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7. Replacement Information
Do you have any existing annuity or life insurance contracts? // Yes // No
Will this annuity replace or change any existing annuity or life insurance?
// Yes // No (If Yes, complete the following and appropriate form(s), i.e.
1035 Exchange or IRA/TSA Transfer plus any applicable state replacement form)
Company __________________________________ Policy No. ___________________
Date Policy Issued _______________________
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8. Dollar-Cost Averaging Program (Subject to State availability)
// Short Term Dollar Cost Averaging Fixed Account - money will be transferred in
equal monthly installments for ___ months*
// Extended Short Term Dollar Cost Averaging Fixed Account - money will be
transferred in equal monthly installments for ___ months*
// Money Market - please transfer $_____ from the Money Market Portfolio each
month starting __/__/__.
Please allocate the amount above to the sub-accounts specified below:
*Contact Glenbrook for current transfer period offered.
Note: Dollar-Cost Averaging into the Fixed Accounts is not available.
This agreement ends automatically when the account value in the sub-account
selected above has been depleted.
Sub-account % or $ Sub-account % or $
__________________ ______ _________________________ ______
__________________ ______ _________________________ ______
__________________ ______ _________________________ ______
__________________ ______ _________________________ ______
__________________ ______ _________________________ ______
Total = 100%
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9. Automatic Portfolio Rebalancing Program
On a quarterly basis, please complete a transfer between the Variable
Sub-accounts to achieve the ending percent allocation below:
None of the money allocated to the MVA or DCA Fixed Accounts will be transferred
as a result of this rebalancing program.
// Keep in effect until notified otherwise.
// Stop the Rebalancing Program on __/__/__.
Sub-account % Sub-account %
__________________ ______ _________________________ ______
__________________ ______ _________________________ ______
__________________ ______ _________________________ ______
__________________ ______ _________________________ ______
__________________ ______ _________________________ ______
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10. Automatic Additions Program
I authorize Glenbrook Life and Annuity Company (Glenbrook) to begin automatic
debits from the account designated below. The funds withdrawn from this account
shall be added to my annuity as an Automatic Addition (Purchase Payment) to the
sub-accounts specified below:
The debit amount is $_______. The debits should begin in ______________.
(Month)
Debit my (check one) // Checking Account // Savings Account
on the (check one) // 5ht day or // 25th day of each (check one)
// Month or // Quarter
Financial Institution ___________________________________________
Address _________________________________________________________
ABA No. ______________________ Acct. No. ________________________
Please allow three business days for the payment to be credited to your annuity.
A VOIDED BLANK CHECK FOR THE ABOVE ACCOUNT MUST BE ATTACHED.
// Keep the Automatic Addition Program in effect until notified otherwise.
// Stop the Automatic Addition Program on __/__/__.
Sub-account % or $ Sub-account % or $
__________________ ______ _________________________ ______
__________________ ______ _________________________ ______
__________________ ______ _________________________ ______
__________________ ______ _________________________ ______
__________________ ______ _________________________ ______
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11. Systematic Withdrawal Authorization
I hereby authorize Glenbrook Life and Annuity Company to make withdrawals of the
amount indicated below. I understand that withdrawals may result in taxable
income and, prior to owner's age of 59 1/2, may be subject to a 10% federal
penalty. The Glenbrook ________ Variable Annuity allows up to 15% of purchase
payments to be withdrawn each contract year. Withdrawals that exceed 15% may be
assessed a withdrawal charge.
Please check frequency: // Monthly // Quarterly // Semi-Annually // Annually
Start Date: __/__/__
// Gross partial withdrawal. the check may differ from the requested amount due
to applicable charges, adjustments or income tax withholding.
Gross Amount $_____.
// Net partial withdrawal. The check amount will equal the request amount. The
Account Value will be reduced to reflect the amount received, as well as
applicable charges, adjustments and income tax withholding. Net Account $____.
Specify percentage or dollar amount to be withdrawn from each sub-account.
Sub-account % or $ Sub-account % or $
__________________ ______ _________________________ ______
__________________ ______ _________________________ ______
__________________ ______ _________________________ ______
__________________ ______ _________________________ ______
__________________ ______ _________________________ ______
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11a. Withholding Election (Required)
// I do want to have ______% federal tax withheld. If no percentage is
indicated, 10% will be withheld.
// I do not want to have federal income tax withheld. Federal Income tax will
be withheld unless this box is checked.
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11b. Direct Deposit
Please deposit the above amount to: (check one) // Checking Account // Savings
Account
Financial Institution ___________________________________________
Address _________________________________________________________
ABA No. _____________________________ Acct. No. _________________
Please allow two business days for the payment to be credited to your account.
A VOIDED BLANK CHECK FOR THE ABOVE ACCOUNT MUST BE ATTACHED
If, instead of a direct deposit, you wish to have a check mailed to you,
complete the following:
Xxxxx's Name __________________________ Acct. No.* __________________
*if applicable
Address _____________________________________________________________
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Notice of Withholding
You may elect not to have federal income tax withheld from the taxable portion
of your distribution by contacting Glenbrook Life and Annuity Company. A
withholding election will remain in effect until revoked, which you may do at
any time. If you do not make payments of estimated tax, and do not have enough
tax withheld, you may be subject to penalities under the estimated tax rules.
GA, IA, MA, ME, OK, OR, VA and VT residents: If you choose to have federal
income tax withheld, depending on the type of distribution, the laws of you
state may require that state income tax be withheld. CA residents: If you
choose to have federal income tax withheld, the laws of your state require that
state income tax be withheld unless you specifically elect not to have state
income tax withheld. You may contact us at any time to change or revoke your
election. CT and MT residents: You may elect to have state income tax
withheld. The withholding rate on withdrawals which are not distributions from
a plan qualified under Internal Revenue Code Sections 401 or 403(b) is 10% of
the taxable portion of the withdrawal. Distributions from a plan qualified
under Internal Revenue Code Section 401 or 403(b) may be subject to 20%
withholding. If you request such a distribution, you will receive a notice
outlining the applicable rules.
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12. Special Instructions
// I would like to receive a Statement of Additional Information (SAI).
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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13. Signature(s)
If this application is declined, Glenbrook Life and Annuity Company will have
not liability except to return the purchase payment. I understand that any
distribution from a Fixed Account prior to the end of a rate guarantee period
may be subject to a Market Value Adjustment which may be negative or positive. I
understand that annuity values and income payments based on the investment
experience of a variable account are variable and are not guaranteed as to
dollar amount. I have received the current prospectus for this variable annuity.
I have read the above statements and any applicable fraud warning for my state.
I represent that the information I have provided is complete and true to the
base of my knowledge and belief.
Signed at _____________________________________ Date __/__/__
City State
Owner(s) Signature(s) _______________________________________
_______________________________________
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14. Agent Use Only
To the best of my knowledge, the insured has an existing annuity or life
insurance contract. // Yes // No
Will the annuity applied for replace or change any existing annuity or life
insurance? // Yes // No
Agent Name (Please print) _______________________ Phone No. ( )_______
Agent Signature _________________________________ Soc. Sec. No. _____-____-____
Florida License ID number ______________________ Agent Option /A/ /B/ /C/ /D/
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IMPORTANT INFORMATION
For applicants in Arizona: Upon your written request we will provide you, within
a reasonable period of time, reasonable 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 contract, you may return the
contract within ten days after you receive it. If the contract you are applying
for is a variable annuity, you will receive an amount equal to the sum of (i)
the difference between the premiums paid and the amounts allocated to any
account under the contract and (ii) the Contract Value on the date the returned
contract is received by our company or our agent.
For applicants in Arkansas, Kentucky, Maine, New Mexico, Ohio, and Pennsylvania:
Any person who knowingly and with intent to defraud and 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, which is a crime and suspects such person to criminal
and civil penalities.
For applicants in 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 of agent of an insurance company who knowingly provides false,
incomplete, or misleading facts or information to a policy holder or claimant
for the purpose of defrauding or attempting to defraud the policy holder 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.
For applicants in the District of Columbia: Warning: It is a crime to provide
false or misleading information to an insurer for the purpose of defrauding the
insurer or any other person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefit if false information materially
related to a claim was provided by the applicant.
For applicants in Florida: Any person who knowingly and with intent to injure,
defraud, or deceive any insurer files a statement of claim or on an application
containing any false, incomplete, or misleading information is guilty of a
felony of the third degree.
1. Annuities are not FDIC Insured:
2. Annuities are not obligations of this bank:
3. The financial institution does not guarantee performance by the insurer
issuing the annuity.
4. Variable annuities involve investment risk, including potential loss of
principal.
5. Variable annuities are not protected by the Securities Investor Protection
Corporation (SIPC) as to the loss of the principal amount invested.
For applicants in Louisiana: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
For applicants in 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.
Mailing Address: Glenbrook Life and Annuity Company
P.O. Box 94042
Palatine, Illinois 60094
Sales Support: AFD inc: 0-000-000-0000
Overnight Address: Glenbrook Life and Annuity Company
000 X. Xxxxxxxxx Xxx.
Vernon Hills, Illinois 60061
Customer Service: 0-000-000-0000
The Glenbrook _______________ Variable Annuity is a flexible premium deferred
variable annuity issued by Glenbrook Life and Annuity Company and underwritten
by ALFS, Inc. Both are subsidiary affiliates of Allstate Life Insurance Company,
headquartered in Northbrook, Illinois. The Glenbrook ______________ Variable
Annuity is sold though agreements with unaffiliated registered representatives,
broker-dealers, and bank employees who are licensed annuity representatives.
Please read the prospectus carefully before you invest or send money.
GLARXXXCW
