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EXHIBIT 5(a)
__________________________________________________________________________
ANNUITY APPLICATION
__________________________________________________________________________
Independence Plus Fixed and Variable Annuity
Impact Fixed and Variable Annuity
GUP Fixed and Variable Annuity
V-Plan Fixed Annuity
Please print clearly. Due to the processing used by VALIC, do not
highlight any information on this form or write in margins.
Upon completion, the original form is sent to VALIC's home office.
One copy goes to the participant and the other copy goes to the field office.
[VALIC LOGO]
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ANNUITY APPLICATION Page 1 of 2
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REGIONAL OFFICE USE ONLY: Date of Input: _______________________________________
APPLICANT/ANNUITANT INFORMATION
SS# or Tax ID#: ________________________________________________________________
Name: __________________________________________________________________________
Address: _______________________________________________________________________
City: __________________________________________________________________________
State: ____________________________________________ Zip: ___________-__________
Date of Birth: ___________/___________/____________
Sex: [ ] Male [ ] Female
Marital Status: [ ] Married [ ] Single
Occupation: ____________________________________________________________________
Home Phone: (_____________)_____________________________________________________
EMPLOYMENT INFORMATION
Employer Name: _________________________________________________________________
Group #: ________________________________ Date of Hire: _______/_______/_______
Work Phone: (_____________)_____________________________________________________
Annual Salary: _________________________________________________________________
Expected Annuity Date: __________/__________/___________
OWNER (NQDA) (Only if other than applicant.)
SS# or Tax ID#: ________________________________________________________________
Name: __________________________________________________________________________
Address: _______________________________________________________________________
City: __________________________________________________________________________
State: ____________________________________________ Zip: ___________-__________
Date of Birth: ___________/___________/____________
Home Phone: (_____________)_____________________________________________________
INVESTOR PROFILE (If required)
Investment Objectives (check one):
[ ] Safety of Principal [ ] Long-term growth
[ ] Retirement Income [ ] Income
[ ] Other_________________________________________________________________
Financial Situations (approximate amounts in thousands):
Under $50 $50-$100 Over $100
Household Income [ ] [ ] [ ]
Net Worth [ ] [ ] [ ]
Life Insurance [ ] [ ] [ ]
Dependents: Number: _______________ Age(s): ___________________________________
______________________________________________________________________________________________________________________________
Provide investment option name,
division number, and the percent to
Date Exclude Product be allocated to each. (Percents must
Contribution Contribution: # of Annualized pymt periods type be whole numbers totaling 100%)
Source % or $ pymts. amount begins from-to (Choose one) Not applicable to V-Plan.
______________________________________________________________________________________________________________________________
[ ] Indepen- ________________________ ________%
Periodic dence Plus ________________________ ________%
________________________ ________%
Employee _______________________________________________________________ [ ] Impact ________________________ ________%
Voluntary ________________________ ________%
(1) Single [ ] GUP ________________________ ________%
Sum ________________________ ________%
[ ] V-Plan ________________________ ________%
___________________________________________________________________________________________________________________
This line is for VALIC
administrative use only: Product: ________ Plan type: ________ Plan #:_____ Sub Group: _____ Account #: _________
______________________________________________________________________________________________________________________________
[ ] Indepen- ________________________ ________%
Periodic dence Plus ________________________ ________%
________________________ ________%
Employee _______________________________________________________________ [ ] Impact ________________________ ________%
Matched ________________________ ________%
(2) Single [ ] GUP ________________________ ________%
Sum ________________________ ________%
[ ] V-Plan ________________________ ________%
___________________________________________________________________________________________________________________
This line is for VALIC
administrative use only: Product: ________ Plan type: ________ Plan #:_____ Sub Group: _____ Account #: _________
______________________________________________________________________________________________________________________________
[ ] Indepen- ________________________ ________%
Periodic dence Plus ________________________ ________%
________________________ ________%
Employer _______________________________________________________________ [ ] Impact ________________________ ________%
Basic ________________________ ________%
(3) Single [ ] GUP ________________________ ________%
Sum ________________________ ________%
[ ] V-Plan ________________________ ________%
___________________________________________________________________________________________________________________
This line is for VALIC
administrative use only: Product: ________ Plan type: ________ Plan #:_____ Sub Group: _____ Account #: _________
______________________________________________________________________________________________________________________________
[ ] Indepen- ________________________ ________%
Periodic dence Plus ________________________ ________%
________________________ ________%
Employee _______________________________________________________________ [ ] Impact ________________________ ________%
Supple- ________________________ ________%
mental Single [ ] GUP ________________________ ________%
(4) Sum ________________________ ________%
[ ] V-Plan ________________________ ________%
___________________________________________________________________________________________________________________
This line is for VALIC
administrative use only: Product: ________ Plan type: ________ Plan #:_____ Sub Group: _____ Account #: _________
______________________________________________________________________________________________________________________________
Initial Flexible Payment Amount: _________________________________________
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ANNUITY APPLICATION Page 2 of 2
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REPLACEMENT
Is this a replacement of an existing annuity or life insurance contract?
[ ] No [ ] Yes If yes, complete the following:
Insured's Name: ________________________________________________________
Policy Number(s):_______________________________________________________
Insurer's (Company) Name:_______________________________________________
BENEFICIARY DESIGNATION
Indicate Name, Address, Relationship, Date of Birth, and Social Security/Tax
Identification Number for any person or entity named as a beneficiary (see
information and instructions page). If additional space is needed, you may use a
separate signed and dated sheet and attach it to this form.
If you are married and are naming someone other than your spouse as your primary
beneficiary, please complete the ERISA Spousal Consent section.
Primary Beneficiary:____________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Contingent Beneficiary:_________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
XXXXX COVERED PLANS: Your spouse must be your primary beneficiary unless spousal
consent to waive Pre-retirement Death Benefits is given. Complete the following
section if naming someone other than spouse as the primary beneficiary.
For missing spouse: I hereby affirm that I have made all reasonable attempts to
locate my spouse and have not been able to do so, and I have no reason to
believe that I will be able to do so.
_____________________________________________ _______________________
Participant Signature Date
Spousal consent to waiver of pre-retirement death benefits: I, the spouse of the
named participant, hereby waive the qualified pre-retirement survivor annuity
provided under Sec. 205 of ERISA as amended by REACT. I understand that in
accordance with this waiver, any death benefits named prior to the time annuity
payments begin, shall be paid to the beneficiary designated by the participant.
If participant is under age 35, the law requires that the spouse receive at
least 50% of the death benefit.
Name of Spouse:_________________________________________________________
________________________________________________ ____________________
Spousal Signature Date
State of _________________________ County of ___________________________
on this ____________________ day of __________________________, 19 _____
________________________________________________________________________
Plan Administrator or Notary Signature (required)
APPLICANT AFFIRMATIONS AND STATEMENTS
This application is subject to acceptance by the Company at its Home Office.
Proof of age must be furnished before Annuity Payments begin. Upon written
request, we will provide you with factual information regarding the benefits and
provisions of the annuity contract for which you are applying. If you are not
satisfied with your annuity contract for any reason, you may return it within 20
days after receipt for a refund of premium (applicable to all individual and
some group contracts). A current prospectus for the Company's Separate Account
was provided with the application. Also a current prospectus was provided for
each Fund available under this Plan. The prospectus for the Separate Account
gives sales expenses and other data.
Annuity Payments or Surrender Values are variable when based on the investment
experience of the Separate Account. They are not guaranteed as to dollar amount.
By signing this form I represent that all statements and answers made in the
application are full, complete, and true to the best of my knowledge and belief.
I have read and understand the information provided on the information and
instruction page on the following subjects:
o Fraud Warning
o Texas Optional Retirement Program (if applicable)
o Salary Reduction Agreement for 403(b) and 401(k) Plans
o Withdrawal Restrictions for 403(b) Plans
[ ] Check if you currently own or participate in another VALIC Annuity Contract.
________________________________________________________________________
Annuitant's Signature
Dated at ________________________, date ________________________, 19____.
________________________________________________________________________
Owner's Signature
Dated at _________________________, date _______________________, 19___.
REPRESENTATIVE OF RECORD
No. ______________________ Issue State (Abv): __________________________
Region Code: ___________________ Branch Code: __________________________
As representative I [ ] do [ ] do not have reason to believe that replacement
of existing life insurance or annuity may be involved.
________________________________________________________________________
Print Licensed Agent/Registered Representative Name
________________________________________________________________________
Licensed Agent/Registered Representative Signature
State License ID #:_____________________________________________________
_______________________________________________________ _______________
Principal's Approval Date
Date of Input: _________________________________________________________
Week Ending: ___________________________________________________________
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INFORMATION AND INSTRUCTIONS
FRAUD WARNING
In some states we are required to advise you of the following: Any person who
knowingly intends to defraud or facilitates a fraud against an insurer by
submitting an application or filing a false claim, or makes an incomplete or
deceptive statement of a material fact, may be guilty of insurance fraud.
Florida Residents Only: An person who knowingly and with intent to injure,
defraud or deceive any insurer, files a statement of claim or an application
containing any false, incomplete or misleading information, is guilty of a
felony of the third degree.
For Colorado, Kentucky and Pennsylvania Residents Only: Any person who
knowingly and with intent to defraud any 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 subjects each person to criminal and civil
penalties.
New Jersey Residents Only: Any person who includes any false or misleading
information on an application for an insurance policy is subject to criminal
and civil penalties.
TEXAS OPTIONAL RETIREMENT PROGRAM REDEMPTION INFORMATION:
o Benefits in the Texas Optional Retirement Program vest after one year of
participation in one or more optional retirement plans.
o Benefits under the Texas Optional Retirement Program are available to you
only after you attain the age of 70 1/2 years, or terminate participation by
death, retirement, or termination of employment in all Texas institutions of
higher education.
o VALIC will require written verification from the program administrator of
your qualification for any requested redemption of any annuity benefits
purchased under the Texas Optional Retirement Program.
WITHDRAWAL RESTRICTIONS FOR 403(b) PARTICIPANTS
According to federal tax laws regulating certain 403(b) plans, any interest and
earnings credited to your account after 12/31/88 and any elective contributions
made after that date may be withdrawn only under any of the following
circumstances.
o Separation from service o Disability
o Age 59 1/2 or older o Hardship (Contributions only)
o Death
Your employer's plan may contain other withdrawal restrictions. Additionally,
some employer plans have alternative investment options among which plan
participants may transfer contract values.
BENEFICIARY DESIGNATIONS (Primary and/or Contingent)
A beneficiary should always be designated. Beneficiary categories are:
PRIMARY BENEFICIARY - One who receives any benefits after the Annuitant dies.
CONTINGENT BENEFICIARY - One who receives any benefits if the primary
beneficiary dies before the Annuitant dies.
Beneficiaries can be an INDIVIDUAL, an INSTITUTION, or a TRUSTEE.
NAMING YOUR BENEFICIARY
INDIVIDUAL as beneficiary: Xxxx X. Xxx
INSTITUTION as beneficiary (Full legal name and address should be stated; also
state whether the institution is a corporation):
The Evergreen Company, a Texas Corporation
TRUSTEE as beneficiary (Named inter vivos [living] trust agreement):
XYZ Bank and Trust Company or its successors, as Trustee under trust
agreement dated January 31, 1982.
SALARY REDUCTION AGREEMENT FOR 403(b) AND 401(k) PLANS
The Employer is hereby or by a separate document authorized and directed to
reduce your pay in the amount indicated under Contribution Information
beginning on the date indicated on this form and to purchase a
non-transferable annuity contract qualified under Section 403(b) of the
Internal Revenue Code (IRC) or a non-transferable annuity contract to provide
retirement benefits under IRC Section 401(k) from The Variable Annuity Life
Insurance Company. This agreement shall be effective for only those amounts not
currently available as of the date indicated on this form. This agreement shall
terminate any prior salary reduction agreement executed between you and the
employer. This agreement shall be legally binding as to both the parties hereto
while employment continues; provided, however, that either party may change or
terminate this agreement with respect to amounts that have not become currently
payable by the Employer and in accordance with Employer's reasonable
administrative procedures. Salary reductions are to be effective with respect
to pay dates on or after the date listed under Date Payment Begins (which is
subsequent to this agreement). Only amounts not currently available to the
employee are eligible for salary reduction.
CONTRIBUTION INFORMATION
o Contribution Sources:
EE(1) - Employee Voluntary;
EE(2) - Employee Mandatory or Matched;
EE(3) - Employer Basic;
EE(4) - Employer Supplemental or Matching
Note: Separate account numbers must be set up for each Contribution Source.
o Choose either a percent of salary or an amount, and fill in the number of
payments, and the date you will begin making payment.
o When the contract applied for is to be used as a periodic payment (salary
reduction or deduction) type plan, please indicate the "from-to" dates for
the Exclude Periods, when applicable.
o Complete Product, Plan Type, and Plan Number
INVESTMENT OPTION ALLOCATION (Not Applicable to V-Plan)
Independence Plus Fixed and Variable Annuity
Purchase payments may be allocated to the Fixed Investment Options and/or
Variable Investment Options. Purchase Payments may be allocated among as many
as seven investment options. The following indicates the current Purchase
Payment allocation choices available.
1 - Fixed Account Plus 9 - Not in use
2 - Short Term Fixed Account 10 - Stock Index Fund
3 - Not in use 11 - International Equities Fund
4 - MidCap Index Fund 12 - Social Awareness Fund
5 - Asset Allocation Fund 13 - International Government
6 - Money Market Fund Bond Fund
7 - Capital Conservation Fund 14 - Small Cap Index Fund
8 - Government Securities Fund
Impact Fixed and Variable Annuity
Purchase Payments may be allocated to the Short Term Fixed Account, and/or
Separate Account Divisions (Investment Vehicles). Purchase Payments may not be
allocated to more than three Investment Vehicles of the Separate Account, or to
two Investment Vehicles of the Separate Account and the Short Term Fixed
Account, at any one time. The following indicates the current Purchase Payment
allocation choices available.
(1) Vehicle 1 - Capital Conservation Fund
(2) Vehicle 2 - Money Market Fund
(3) Vehicle 3 - Stock Index Fund
(4) Vehicle 4 - MidCap Index Fund
(5) Vehicle 5 - Asset Allocation Fund
(6) Short Term Fixed Account
GUP 64/74 Fixed and Variable Annuity
Purchase Payments may be allocated to the Fixed Account, to the Variable
Account, or any combination (whole percentages) of the two.
OWNER vs. ANNUITANT (NQDAs Only)
The owner and the annuitant may be different only for Non-Qualified Deferred
Annuities (NQDAs). The owner has most of the rights under the contract. The
annuitant is the person upon whose life expectancy the contract benefits are
based.
VALIC HOME OFFICE
0000 Xxxxx Xxxxxxx, Xxxxxxx, XX 00000
Contact your Regional Office for customer assistance at 1-800-44-VALIC.
