Exhibit (5)(d)
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XX Xxx 0000, Xxxxxxxxxx, Xxxx 00000-0000 (000) 000-0000
APPLICATION FOR GROUP FLEXIBLE PREMIUM DEFERRED ANNUITY CONTRACT
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1) OWNER INFORMATION
PROPOSED CONTRACT OWNER:
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MAILING ADDRESS:
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BILLING CONTACT:
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Telephone Number ( ) Fax Number ( )
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MAIL BILLING STATEMENT TO (IF OTHER THAN THIRD PARTY ADMINISTRATOR (IF
ABOVE): APPLICABLE):
Name: Firm:
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Address: Address:
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City, State Zip: City, State Zip:
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Contact:
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Telephone Number: ( )
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2) PRODUCT INFORMATION
The Application is for investment in the AILIC Contract:
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3) PLAN INFORMATION
PLAN NAME: PLAN NUMBER: / / / / / /
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TAX ID NUMBER: PLAN YEAR END: Month Day
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PLAN TYPE: / / 401(a) / / 401(k) / / ERISA 403(b)
/ / NonERISA 403(b) / / 457 / / Other (Specify)
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PLAN ADMINISTRATOR/TRUSTEE TELEPHONE NUMBER: ( )
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4) AGREEMENT
Application is hereby made for a Group Flexible Premium Deferred Annuity
Contract. The Owner acknowledges that Annuity Investors Life Insurance Company
(REGISTERED) will provide the investment vehicle for, but will not be
responsible for the administration of the plan. The Owner hereby agrees that the
Contract shall not take effect and be in force unless and until the first
premium is received by the COMPANY. The Owner has read and understands this
entire application. The Owner has also received current copies of the
prospectuses for the Annuity Investors Variable Account and Funds which
correspond to the product selected in section 2 of this application.
IT IS FURTHER UNDERSTOOD THAT PAYMENTS AND VALUES PROVIDED UNDER EACH
CERTIFICATE, WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT,
ARE VARIABLE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT.
The information provided herein is true, correct, and complete to the best of my
knowledge and belief.
Signed at: this day of , in the year .
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City, State Day Month Year
Signature for Owner: Title:
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Signature of COMPANY Representative:
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FOR HOME OFFICE USE ONLY:
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