DA _____________
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Allianz Life Insurance Company of North America
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[Allianz Elite(TM)]
Individual Limited Purchase Payment Variable Deferred Annuity Application
Issued by Allianz Life Insurance Company of North America (Allianz Life),
Minneapolis, MN
Countrywide except NY
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1. ACCOUNT REGISTRATION
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Owner is Individual (must be age [80] or younger.)
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Individual Owner First Name Middle Initial Last Name (Jr or Sr), or III
Owner is __Trust __Qualified Plan __Custodian (If Trust, please include the date
of Trust in the name.)
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Non-Individual Owner Information
If Trust is Owner, please refer to Trustee Representation form.
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Tax ID number Social Security number
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Street Address
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City State ZIP Code Daytime telephone number
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Sex __M __F Date of Birth (mm/dd/yyyy)
Are you a U.S. Citizen? __Yes No__ If no, need W8-BEN.
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JOINT OWNER(Optional) (Must be the spouse of the Contract Owner except in the
states of CA, NJ, OR and PA.) (Must be age [80] or younger.)
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First Name Middle Initial Last Name (Jr or Sr), or III
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Street Address
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City State ZIP Code Daytime telephone number
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Sex __M __F Date of Birth (mm/dd/yyyy) Social Security number
Are you a U.S. Citizen? __Yes No__ If no, need W8-BEN.
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Relationship to Owner
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ANNUITANT (Must complete if different than Owner.) (Must be age [80] or
younger.)
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First Name Middle Initial Last Name (Jr or Sr), or III
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Street Address
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City State ZIP Code Daytime telephone number
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Sex __M __F Date of Birth (mm/dd/yyyy) Social Security number
Are you a U.S. Citizen? __Yes No__ If no, need W8-BEN.
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2. PURCHASE PAYMENT
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This section must be completed. Please make check payable to Allianz Life.
$25,000 minimum Purchase Payment required.
____Purchase Payment enclosed with application
Purchase Payment amount $_______________________
____This contract will be funded by a 1035 exchange, Tax Qualified
Transfer/Rollover, CD Transfer or Mutual Fund Redemption.(If checked, please
include the appropriate forms.)
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3. PLAN SPECIFICS
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This section must be completed to indicate how this contract should be issued.
NonQualified:__
Inherited IRA's: __IRA __Roth XXX __SEP XXX
(Not available with Short Withdrawal Charge Option)
Qualified IRA's: __IRA __Roth XXX __SEP XXX
__Roth Conversion (Contribution for tax year_______)
Qualified Plans: __403(b)(90-24 transfer) __401 __401 One Person Defined Benefit
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4. REPLACEMENT
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This section must be completed.
Do you have existing life insurance or annuity contracts?
(If yes, submit NAIC forms.)__YES* __No
If yes, will the annuity contract applied for replace or change existing
contracts or policies? __YES* __No
The Registered Representative must answer the replacement question in
section 12 of this application. *Please include all required replacement forms.
F40460
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5. INCOME BENEFIT OPTION
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YOU MUST SELECT whether or not to receive the PRIME Plus Benefit.
To receive the PRIME Plus Benefit you must check the following box:
__PRIME Plus Benefit (Available to owners age [75] or younger at time of
selection Carries an additional cost.)
BY SELECTING THE PRIME PLUS BENEFIT, I CONSENT THAT ALLIANZ LIFE MAY REALLOCATE
MY CONTRACT VALUE IN ACCORDANCE WITH THE ASSET ALLOCATION AND TRANSFER
PROVISIONS IN THE CONTRACT.
If you do not want to receive the PRIME Plus Benefit you must check the
following box:
__No PRIME Plus Benefit (No additional cost.)
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6. DEATH BENEFIT OPTION
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To receive the Enhanced Guaranteed Minimum Death Benefit you must check the
following box:
__Enhanced Guaranteed Minimum Death Benefit (Optional) (Available to owners age
[75] or younger on the Issue Date.)(Carries an additional cost.)
(Once selected, it cannot be changed.)
IF NO SELECTION IS MADE, THE TRADITIONAL GUARANTEED MINIMUM DEATH BENEFIT
(no additional cost) WILL APPLY.
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7. SHORT WITHDRAWAL CHARGE OPTION
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To receive the Short Withdrawal Charge Option you must check the following box:
__Short Withdrawal Charge Option (Carries an additional cost.)
(Once selected, it cannot be changed.)
IF NO SELECTION IS MADE THE STANDARD WITHDRAWAL CHARGE OPTION
(NO ADDTIONAL COST) WILL APPLY.
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8. PURCHASE PAYMENT ALLOCATION
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[COMPLETE THIS SECTION FOR ALLOCATIONS AND DOLLAR COST AVERAGING (DCA) SOURCE
INVESTMENT CHOICES. You may select up to [15] Investment Choices. Must use whole
percentages (33.3% or dollars are not permitted). Total of percentages in this
section must total 100%.
PLEASE NOTE: If DCA is being requested, DCA form must be attached to indicate
which Investment Choices you wish to dollar cost average into. If this DCA form
is NOT attached and you request DCA, we cannot invest your Purchase Payement.
DCA FIXED OPTIONS (DCA Form must be attached.)
__% 12-Month DCA Fixed Option
__% 6-Month DCA Fixed Option
FUSIONPORTFOLIO
__% AZL Fusion Balanced Fund(SM)
__% AZL Fusion Growth Fund(SM)
__% AZL Fusion Moderate Fund(SM)
SMALL CAP
__% AZL Dreyfus Premier Small Cap Value Fund(SM)
__% AZL Franklin Small Cap Value Fund(SM)
__% AZL Xxxxxxxxxxx Emerging Growth Fund(SM)
__% AZL Salomon Brothers Small Cap Growth Fund(SM)
__% Dreyfus IP Small Cap Stock Index Fund
MID CAP
__% AZL Xxxxxxxxx Xxxxxx Regency Fund(SM)
__% AZL OCC Renaissance Fund(SM)
__% AZL Xxx Xxxxxx Aggressive Growth Fund(SM)
__% AZL Xxx Xxxxxx Mid Cap Growth Fund(SM)
__% OpCap Mid Cap Portfolio
LARGE GROWTH
__% AZL Dreyfus Founders Equity Growth Fund(SM)
__% AZL Xxxxxxxx Growth Fund(SM)
__% AZL Xxxx Xxxxx Growth Fund(SM)
__% AZL Salomon Brothers Large Cap Growth Fund(SM)
__% AZL Xxx Xxxxxx Emerging Growth Fund(SM)
INTERNATIONAL EQUITY
__% AZL AIM International Equity Fund(SM)
__% AZL Xxxxxxxxxxx Global Fund(SM)
__% AZL Xxxxxxxxxxx International Growth Fund(SM)
__% AZL Xxx Xxxxxx Global Franchise Fund(SM)
__% Mutual Discovery Securities Fund
__% Xxxxxxxxx Foreign Securities Fund
__% Templeton Growth Securities Fund
LARGE BLEND
__% AZL Xxxxxxxx 20/20 Focus Fund(SM)
__% AZL Xxxx Xxxxx Value Fund(SM)
__% AZL Xxxxxxxxxxx Main Street Fund(SM)
__% AZL PIMCO Fundamental IndexPLUS Total Return Fund(SM)
__% Dreyfus Stock Index Fund
__% Franklin Large Cap Growth Securities Fund
LARGE VALUE
__% AZL AIM Basic Value Fund(SM)
__% AZL Xxxxx NY Venture Fund(SM)
__% AZL OCC Value Fund(SM)
__% AZL Xxx Xxxxxx Xxxxxxxx Fund(SM)
__% AZL Xxx Xxxxxx Growth and Income Fund(SM)
__% Franklin Growth and Income Securities Fund
__% Mutual Shares Securities Fund
HIGH YIELD BONDS
__% Franklin High Income Fund
__% PIMCO VIT High Yield Portfolio
INTERMEDIATE-TERM BONDS
__% Franklin Zero Coupon Fund - 2010
__% PIMCO VIT Emerging Markets Bond Portfolio
__% PIMCO VIT Global Bond Portfolio (Unhedged)
__% PIMCO VIT Real Return Portfolio
__% PIMCO VIT Total Return Portfolio
SHORT-TERM BONDS
__% Franklin U.S. Government Fund
CASH EQUIVALENT
__% AZL Money Market Fund(SM)
SPECIALTY
__% AZL Xxxxxxxxxxx Developing Markets Fund(SM)
__% AZL Columbia Technology Fund(SM)
__% AZL Xxx Xxxxxx Equity and Income Fund(SM)
__% AZL Xxx Xxxxxx Global Real Estate Fund(SM)
__% Xxxxx VA Financial Portfolio
__% Franklin Global Communications Securities Fund
__% Franklin Income Securities Fund
__% PIMCO VIT All Asset Portfolio
__% PIMCO VIT Commodity RealReturn Strategy Portfolio
TOTAL of _____________________%
(Must equal 100%)]
[Flexible Reblancing Quarterly: __By checking this box you are selecting
Flexible Rebalancing on a QUARTERLY basis. Your Contract will be rebalanced
quarterly based on the same allocations as indicated above. This feature is not
available if you have selected an Dollar Cost Averaging Program.
If you are requesting any other mode than quarterly for Flexible Rebalancing,
please complete the Flexible Rebalancing form.
F40460
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9. TRANSFER AUTHORIZATION
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___ Yes
By checking "yes," I am authorizing and directing Allianz Life to act on
instructions from the registered representative and/or anyone authorized by
him/her to transfer Contract Values among the Investment Choices. IF THE
BOX IS NOT CHECKED, ONLY THE WONER OR THERI DESIGNATE WILL BE PERMITTED TO
MAKE TRANSFERS. Allianz Life will use reasonable procedures to confirm that
these instructions are authenticicated as genuine. As long as these
procedures are followed, Allianz Life and its affiliates and their
directors, trustees, officers, employees, representatives, and/or agents
will be held harmless for any claim, liability, loss, or cost. The transfer
authorization may be modified or withdrawn at the discretion of the
Company.
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10. BENEFICIARY DESIGNATION
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If the Beneficiary is a Trust, Qualified Plan or Custodian, please check the box
and include the name below __Trust __401 Qualified Plan __Custodian
__Primary __Contingent
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Percentage Tax ID number Social Security number
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Non-Individual Beneficiary Information (If Trust, please include date of Trust
in name.) (If owner is a 401 qualified plan or custodian, the plan or custodian
must be the beneficiary.)
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__Primary __Contingent
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Percentage Tax ID number Social Security number
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First Name Middle Initial Last Name
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Relationship
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__Primary __Contingent
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Percentage Tax ID number Social Security number
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First Name Middle Initial Last Name
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Relationship
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__Primary __Contingent
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Percentage Tax ID number Social Security number
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First Name Middle Initial Last Name
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Relationship
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(If more than 4 beneficiaries, attach a list signed by Owner. At the
Owner's death, the surviving Joint Owner becomes the Primary Beneficiary.)
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11. STATEMENT OF APPLICANT
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The following states require applicants to read and acknowledge the statement
for your state below.
[ARIZONA: Upon your written request, we will provide you with factual
information regarding the benefits and provisions of the Annuity Contract for
which you are applying. If for any reason you are not satisfied with the Annuity
Contract, you may return the Contract within 10 days after you receive it for a
full refund of the Contract Value. IF YOU ARE AGE 65 OR OLDER ON THE DATE OF THE
APPLICATION, YOU MAY RETURN THE CONTRACT WITHIN 30 DAYS AFTER YOU RECEIVE IT FOR
A FULL REFUND OF THE CONTRACT VALUE.
ARKANSAS, KENTUCKY, LOUISIANA, MAINE, NEW MEXICO, OHIO, TENNESSEE AND WEST
VIRGINIA: Any person who knowingly, and with intent to defraud any insurance
company, submits an application or files a statement of claim containing any
false, incomplete, or misleading information, commits a fraudulent insurance
act, which is a crime, may be subject to criminal prosecution and civil
penalties. In ME and TN, additional penalties may include imprisonment, fines,
or a denial of insurance benefits.
COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading
facts or information to an insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may include imprisonment, fines,
denial of insurance, and civil damages. Any insurance company or agent of an
insurance company who knowingly provides false, incomplete, or misleading facts
or information to a policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with regard to a settlement
or award payable from insurance proceeds shall be reported to the Colorado
division of insurance within the department of regulatory agencies.
DISTRICT OF COLUMBIA, PENNSYLVANIA AND VIRGINIA: Any person who knowingly and
with the 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(except VA), which
is a crime and subjects such person to criminal and civil penalties. In DC and
VA, additional penalties may include imprisonment and/or fines, or denial of
insurance benefits.
FLORIDA: Any person who knowingly and with the 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.
NEW JERSEY: Any person who includes any false or misleading information on an
application for an insurance policy is subject to criminal and civil penalties.
VERMONT: I understand that this variable annuity is not a bank deposit; is not
federally insured; is not endorsed by any bank or government agency; is not
guaranteed and may be subject to loss of principal.]
F40460
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11. STATEMENT OF APPLICANT (CONTINUED)
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By signing below, the Owner acknowledges the statements mentioned above and
understands that or agrees to the following:
I received a Prospectus and have determined that the variable annuity applied
for is not unsuitable for my investment objectives, financial situation, and
financial needs. It is a long-term commitment to meet financial needs and goals.
I UNDERSTAND THAT THE CONTRACT VALUE AND VARIABLE ANNUITY PAYMENTS MAY INCREASE
OR DECREASE DEPENDING ON THE INVESTMENT RESULTS OF THE VARIABLE INVESTMENT
CHOICES, AND THAT NO MINIMUM CONTRACT VALUE OR VARIABLE ANNUITY PAYMENT IS
GUARANTEED. 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.
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Owner's signature Joint Owner's signature
(or Trustee, if applicable) (or Trustee, if applicable)
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Signed at (city and state) Date signed __Please send me a Statement of
Additional Information also
available on the SEC web site
(xxxx://xxx.xxx.xxx).
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12. REGISTERED REPRESENTATIVE
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By signing below, the Registered Representative/Agent Certifies to the
following:
I am NASD registered and state licensed for variable annuity contracts in all
required jurisdictions; and I provided the Contract Owner(s) with the most
current Prospectus. To the best of my knowledge the applicant: ___DOES___DOES
NOT have existing life insurance policies or annuity contracts. To the best of
my knowledge and belief, this application ___DOES___DOES NOT involve replacement
of existing life insurance or annuities. If a replacement, include a copy of
each disclosure statement and a list of companies involved.
1. ______________________________________ [-------------
Registered Representative's signature B/D Rep ID
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Registered Representative's first and last name (please print) % Split
2. __________________________________________________ Registered ------------
Representative's signature (split case) B/D Rep ID
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Registered Representative's first (split case) % Split
and last name (please print)
3. __________________________________________________ Registered ------------
Representative's signature (split case) B/D Rep ID
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Registered Representative's first (split case) % Split]
and last name (please print)
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Registered Representative's telephone number
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Registered Representative's address
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Broker/dealer name (please print)
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Authorized signature of broker/dealer (if required)
[Representative's FLORIDA Insurance License Number
(complete if application signed in Florida) ___________________________________]
[Commission Options: (Please check one) __ A __ B __ C __ D
(If choose Short Withdrawal Charge Option can select C or D only)]
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13. HOME OFFICE USE ONLY
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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 Owner(s). Changes to this application that affect
product, benefits, amount of insurance or age require acceptance by the
Owner(s).
[ MAILING INFORMATION
APPLICATIONS THAT HAVE A CHECK ATTACHED
REGULAR MAIL OVERNIGHT, CERTIFIED, OR REGISTERED
Allianz Life-Allianz Service Center Allianz Life-Allianz Service Center 824240
XX Xxx 000000 x/x XXX Xxxx Xxxxxxx
Xxxxxxxxxxxx, XX 00000-0000 Route 38 and Xxxx Xxxx Xxxxx
Xxxxxxxxxx, XX 00000
APPLICATIONS THAT DO NOT HAVE A CHECK ATTACHED
REGULAR MAIL OVERNIGHT, CERTIFIED, OR REGISTERED
Allianz Life-Allianz Service Center Allianz Life-Allianz Service Center
XX Xxx 0000 000 Xxxxxx Xxxx
Xxxxxxxxxxxx, XX 00000-0000 Xxxxxx, XX 00000-0000
For further questions, please call the Allianz Service Center at (800)
624-0197.]
