APPLICATION FORM Aetna Life Insurance and Annuity Company
Group Annuity Contracts 000 Xxxxxxxxxx Xxxxxx, Xxxxxxxx, XX 00000-8022
------------------------------------------------------------------------------------------------------------------------------------
CLIENT 1. Name of applicant/employer
-------------------------------------------------------------------------------------------------------------
INFORMATION 2. Address
-------------------------------------------------------------------------------------------------------------
City State ZIP Code
-------------------------------------------------------------------------------------------------------------
3. Tax Identification No.
-------------------------------------------------------------------------------------------------------------
4. Name of plan (if any)
-------------------------------------------------------------------------------------------------------------
5. Type of plan and section of Internal Revenue Code (if any) under which plan is to qualify:
|_| 403(b) Public School System |_| 457 Public Employer |_| Non-457 Tax-Exempt Deferred
Tax-Deferred Annuity Deferred Compensation Compensation (for select manage-
ment and highly compensated
employees)
Optional Retirement Plan for Higher Education
|_| 403(b) |_| 401(a)
|_| 403(b) for 501(c)(3) Organization
Tax-Deferred Annuity (Organizations formed after |_| 457 Tax-Exempt Deferred
10/9/69 must have IRS ruling regarding 501(c)(3) status) Compensation (for select manage-
|_| Retirement Plus |_| Healthcare Retirement Plus ment and highly compensated
employees)
|_| 401(a) for 501(c)(3) Organization (Organizations
formed after 10/9/69 must have IRS ruling regarding |_| Other: _____________________
501(c)(3) status)
|_| Retirement Plus |_| Healthcare Retirement Plus
|_| 401(k) for 501(c)(3) Organization (Organizations
formed after 10/9/69 must have IRS ruling regarding
501(c)(3) status)
ACCOUNT INFORMATION |_| Retirement Plus |_| Healthcare Retirement Plus
-------------------------------------------------------------------------------------------------------------
6. Is this contract subject to ERISA Title I?
|_| Yes |_| No If yes, Plan anniversary Month _____ Day _____ Plan Beginning Date ______
----------------------------------------------------------- -------------------------------------------------
7. Contract is to be:
|_| Allocated |_| Unallocated 8. Contract effective date
-------------------------------------------------------------------------------------------------------------
9. GAA Maturity Notices should be mailed to:
|_| Participants |_| Employer |_| Participants and Employer
-------------------------------------------- --------------------- ---------------------- -------------------
10. Will this contract change or replace
any existing life insurance or
annuity contract? If yes, please Date to be
|_| Yes |_| No provide Carrier Name Account Number canceled
-------------------------------------------------------------------------------------------------------------
11. Special Requests:
Healthcare 501(c)(3) Organizations:
Withdrawal Fee: |_| 10 year |_| 5 year |_| None
Transfer Bonus: |_| 2% (Option A) |_| None (Option B)
(300-MOP-96)
-------------------------------------------------------------------------------------------------------------
12. Participants may elect the investment allocation for:
INVESTMENT OPTIONS |_| Employer and Employee contributions |_| Employee contributions only |_| None Contract Holder elects
-------------------------------------------------------------------------------------------------------------
13. For Employer directed allocations: Enter the percentage of payment and the investment option
chosen for allocation purposes.
|_| Employer Modal Contributions:_____________________________________________________________________
|_| Employee Modal Contributions:_____________________________________________________________________
|_| Transferred Assets:_______________________________________________________________________________
-------------------------------------------------------------------------------------------------------------
I understand that amounts withdrawn from a GAA Term may be subject to a market value adjustment prior to the
maturity date of that Term as specified in the contract. I further understand that Annuity payments and
account values, (if any), 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
--------------------------------------------------------- ---------------------------------------------
Witness Contract Holder
Home Office Use: Accepted _________
-------------------------------------------------------------------------------------------------------------
PRODUCER'S Do you have any reason to believe any existing life insurance or annuity contract will be modified or
NOTE: replaced if this contract is issued? |_| Yes |_| No
---------------------------------------------------
Signature of Producer
-------------------------------------------------------------------------------------------------------------
Corrections and amendments (Home Office Use Only). Errors and omissions may be corrected by the Company but
no change in plan, classification, amount, age at issue, or extra benefits shall be made without written
consent of the Contract Holder. (N/A in X.XX.)
-------------------------------------------------------------------------------------------------------------
---------------------------------------------------
Affix Prospectus
Receipt Here
---------------------------------------------------
