Franklin Valuemark Classic
A Flexible Premium Variable Annuity
Issued by Allianz Life Insurance Company of North America DA__________
______________________________________________________________________________
1.CONTRACT OWNER Must be age 90 or younger
Name Last First Middle
________________________________________________________________________
(If the Contract Owner is a trust, please include Trust Name, Trust Date,
and the Trust Beneficial Owner(s))
Address Street Address Apartment Number
City State Zip Code
Social Security Number Date of Birth Sex ____Female
(If the Contract Owner is a ____Male
Daytime Telephone ( ) trust, list the date(s) of birth
for the beneficial owner(s))
______________________________________________________________________________
2.JOINT OWNER(Optional)
Must be age 90 or younger. Must be the Spouse of the Contract Owner.
Name Last First Middle
Social Security Number Date of Birth Sex ____Female
____Male
Daytime Telephone ( )
______________________________________________________________________________
3.ANNUITANT
Must be age 90 or younger. Must complete if different than Contract owner.
Name Last First Middle
Address Street Address Apartment Number
City State Zip Code
Social Security Number Date of Birth Sex ____Female
____Male
Daytime Telephone________________Relationship to Contract Owner____________
______________________________________________________________________________
4.BENEFICIARY(IES) DESIGNATION
Primary Beneficiary(ies): Contingent Beneficiary(ies)
(At the Contract Owner's
death, the surviving
Joint Owner becomes the
Primary Beneficiary.)
Name Name
Relationship to Contract Owner Relationship to Contract Owner
Name Name
Relationship to Contract Owner Relationship to Contract Owner
______________________________________________________________________________
5. REPLACEMENT
Is this Annuity intended to replace or change existing life insurance or
annuity? ___Yes - Please include appropriate form.
___ No
______________________________________________________________________________
6. TAX QUALIFIED PLANS
Is this annuity part of a Tax
Qualified Plan? ____ Yes ____No If yes, please select one of the following.
___IRA Transfer/Rollover ___403(b)TSA
___Regular Contribution
for Tax Year________
___Roth IRA ___401 (Corporate Plan)
___Other _______________
______________________________________________________________________________
7.PURCHASE PAYMENT
____Purchase Payment Enclosed with Application
Purchase Payment Amount $_____________________
____This contract will be funded by a 1035 Exchange, Tax Qualified
Transfer/Rollover, CD or Mutual Fund Redemption. (If checked, please
attach the appropriate forms).
______________________________________________________________________________
8.PURCHASE PAYMENT ALLOCATION
You may select up to 10 funds. Use whole percentages. The allocations
you indicate below will become your allocations on all future payments
until you notify us of a change.
CAPITAL GROWTH
___%Capital Growth Fund
___%Global Health Care
Securities Fund INCOME
___%Mutual Discovery Securities Fund ___%High Income Fund
___%Natural Resources Securities Fund ___%Xxxxxxxxx Global Income Securities
___%Small Cap Fund Fund
___%Xxxxxxxxx Developing Markets ___%U.S. Government Securities Fund
Equity Fund ___%Zero Coupon Fund 2005
___%Xxxxxxxxx Global Growth Fund ___%Zero Coupon Fund 2010
___%Xxxxxxxxx International Equity
Fund
___%Xxxxxxxxx International Smaller CAPITAL PRESERVATION AND INCOME
Companies Fund ___%Money Market Fund
___%Xxxxxxxxx Pacific Growth Fund
FIXED
GROWTH AND INCOME ___%Allianz Life Fixed Account
___%Global Utilities Securities Fund (select one of the options below)
___%Growth and Income Fund ___Dollar Cost Averaging Fixed Option
___%Income Securities Fund ___Standard Dollar Cost Averaging Option
___%Mutual Shares Securities Fund
___%Real Estate Securities Fund
___%Rising Dividends Fund
___%Xxxxxxxxx Global Asset Allocation ___TOTAL (Must Equal 100%)
Fund
___%Value Securities Fund
______________________________________________________________________________
9. Premier Protection Package Election
The Franklin Valuemark Classic automatically includes a basic Guaranteed Minimum
Protection Benefit that is applicable to contracts owned for the benefit of an
individual. This provides a death benefit and an income benefit (which provides
for guaranteed minimum payments during the Annuity Payment Period). This benefit
is equal to the greater of : 1)Contract Value or 2) Purchase Payments less
proportionate withdrawals. The income benefit is subject to a 7 year waiting
period.
Check the following box if you want to choose the "Premier Protection Package"
which provides both an enhanced death benefit and an enhanced income benefit. An
additional charge is assessed to the Contract Owner for this feature. Upon
making this selection, it cannot be changed. This selection can only be made at
the time of initial Purchase Payment. Refer to the Prospectus for additional
information.
___The Premier Protection Package includes both a death benefit and an income
benefit determined by the greater of: 1)Purchase Payments less proportionate
withdrawals accumulated at 5% interest on each Contract Anniversary up to the
Contract Owner's attained age of 81; or 2) The greatest Contract Anniversary
Value less proportionate withdrawals up to the Contract Owner's attained age of
81. The income benefit is subject to a 7 year waiting period.
If you do not check this box, you will NOT receive the Premier Protection
Package.
Note: Contracts that are not owned for the benefit of an individual are not
eligible for the Premier Protection Package.
______________________________________________________________________________
10. INCOME DATE
Selected Income Date ___- 01 -___ The Income Date (Annuitization Date) may be
no earlier than two years
after the Issue Date. The income date does
not take effect until at least 7 years
after the Issue Date.
______________________________________________________________________________
11.TELEPHONE AUTHORIZATION
___ I/We authorize Allianz Life Insurance Company of North America (Allianz
Life) to honor telephone instructions from the Contract Owner(s) to transfer
contract values among the funds and the fixed account and to disburse
partial surrenders.
___ I/We authorize Allianz Life Insurance Company of North America (Allianz
Life) to accept telephone instructions from the Registered Rep/Agent of Record
for this contract and/or the Representative's Assistant(s)to transfer contract
values among the funds and the fixed account.
If no selection is indicated, telephone access authorization will be permitted
for the Contract Owner only. This authorization is subject to the terms and
provisions in the contract and Prospectus. Allianz Life will employ reasonable
procedures to confirm that telephone instructions are genuine. If Allianz Life
does not, it may be liable for any losses due to unauthorized or fraudulent
transfers.
For partial withdrawals, Allianz Life's sole responsibility is to send a check
payable to the Contract Owner(s) address, or wire the proceeds to the Contract
Owner's account at a commercial bank (a savings bank may not be used) or to the
Contract Owner's account at a member firm of a national securities exchange.
______________________________________________________________________________
12. BY SIGNING BELOW, THE CONTRACT OWNER UNDERSTANDS THAT OR AGREES TO
I received a Prospectus and have determined that the variable annuity applied
for is not unsuitable for my insurance investment objectives, financial
situation, and financial needs. It is a long term commitment to meet
insurance needs and financial goals. I understand that the annuity value for
payments allocated to the variable sub-accounts may increase or decrease
depending on the contract's investment results, and that no minimum cash value
is guaranteed on the variable sub-accounts. To the best of my knowledge and
belief, all statements and answers in this application are complete and true.
It is further agreed that these statements and answers will become a part of
any contract to be issued. No representative is authorized to modify this
agreement or waive any of Allianz Life's rights or requirements.
___________________________________ ______________________________________
Contract Owner's Signature Joint Owner's Signature (or Trustee,
(or Trustee, if applicable) if applicable)
___________________________________ ______________________________________
Signed At (City, State) Date Signed
____Please send me a Statement of Additional Information
______________________________________________________________________________
00.XX SIGNING BELOW, THE REGISTERED REPRESENTATIVE/AGENT CERTIFIES THAT
-I am NASD registered and state licensed for variable annuity contracts in the
state where this application is written and delivered; and
-I provided the Contract Owner(s) with the most current Prospectus; and
-To the best of my knowledge and belief, this application ___DOES___DOES NOT
involve replacement of existing life insurance or annuities. If replacement,
attach a copy of each disclosure statement and list of companies involved.
___________________________________ ______________________________________
Registered Representative Name (Print) Registered Representative Name (Print)
___________________________________ ______________________________________
Registered Representative Signature Registered Representative Signature
___________________________________ ______________________________________
Broker Dealer Name Authorized signature of Broker Dealer
if required
______________________________________________________________________________
Branch Address Branch Telephone Number
Comm: A B C D (circle one)
______________________________________________________________________________
14.MAIL APPLICATIONS TO
Allianz Life-Valuemark Service Center For Overnight Delivery:
c/o PNC Bank Allianz Life Valuemark Service Center
Box 824240 c/o PNC Bank
Philadelphia, PA 19182-4240 Attn: Box 0000
Xxxxx 00 xxx Xxxx Xxxx Xxxxx
Xxxxxxxxxx, XX 00000-4240
______________________________________________________________________________
15.HOME OFFICE USE ONLY (EXCEPT IN WV)
If Allianz Life Insurance Company of North America makes a change in this
space in order to correct any apparent errors or omissions, it will be
approved by acceptance of this contract by the Owner(s); however, any material
change must be accepted in writing by the Contract Owner(s).
