Aetna Life Insurance and Annuity Company Aetna Growth Plus
Home Office: 000 Xxxxxxxxxx Xxxxxx Xxxxx Xxxxxxx Xxxxxxxx
Xxxxxxxx, Xxxxxxxxxxx 00000-8022 Application
------------------------------------------------------------------------------------------------------------------------------------
Contract Holder 1. Name of Contract Holder
Information
----------------------------------------------------------------------------------------------------------
(Please print or type.) 2. Address
----------------------------------------------------------------------------------------------------------
City State ZIP Code
----------------------------------------------------------------------------------------------------------
3. Tax Identification Number
----------------------------------------------------------------------------------------------------------
4. Contract Effective Date
----------------------------------------------------------------------------------------------------------
5. Type of Contract: [ ] Nonqualified [ ] XXX Xxxxxxxx (IRC Section 408)
----------------------------------------------------------------------------------------------------------
6. Special Requests
----------------------------------------------------------------------------------------------------------
7. I acknowledge receipt of the Aetna Growth Plus Annuity Contract Prospectus dated __________ and all
current prospectuses pertaining to all of the variable investment options under the contract. [ ]
Check here to receive a Statement of Additional Information for the Growth Plus Annuity Contract.
----------------------------------------------------------------------------------------------------------
8. Will this contract change or replace any existing life insurance or annuity contract? [ ] Yes [ ] No
If yes, please provide carrier name, policy number and proposed cancellation date.
----------------------------------------------------------------------------------------------------------
9. The following will receive compensation when Aetna issues the annuity described in this application:
________________________________________________________(to be completed by the agent)
----------------------------------------------------------------------------------------------------------
I understand that any amount withdrawn from the GP Guaranteed Account prior to the maturity date of a
guaranteed term is subject to a market value adjustment as specified in the contract. I further understand
that annuity payments and account values, when based on the investment experience of a Separate Account
are variable and not guaranteed as to fixed dollar amount.
Dated at _______________________________ this ________________ day of _______________ 19____.
City and State
----------------------------------------------------------------------------------------------------------
Contract Holder Title Witness
----------------------------------------------------------------------------------------------------------
Agent's Do you have any reason to believe any existing life insurance or annuity contracts will be modified or
Note replaced if this contract is issued? [ ] Yes [ ] No
--------------------------------------------------------- ------------------------------------------------
Signature of Agent State License (if applicable)
----------------------------------------------------------------------------------------------------------
Home Office Errors and omissions may be corrected by a company agent number but no change in plan, classification,
Use Only amount, or extra benefits can be made without written consent of the Contract Holder. (N/A in W. Va)
Accepted _______________________________
GP1APP(4/94)
