Allianz Life Insurance Company of North America 1750 Hennepin Avenue (Allianz Logo) Minneapolis, MN 55403-2195Annuity Contract • September 18th, 1998 • Allianz Life Variable Account B
Social Security Number Date of Birth Sex ____Female (If the owner is a trust, ____Male Daytime Telephone ( ) list the date(s) of birth for the beneficial owner(s)) ______________________________________________________________________________Flexible Premium Variable Annuity • September 18th, 1998 • Allianz Life Variable Account B
