Application for a Variable Annuity Contract (PLEASE PRINT)
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[LOGO] Value Guard The Guardian Insurance & Annuity Company, Inc.
(The Company)
000 Xxxx Xxxxxx Xxxxx, Xxx Xxxx, X.X. 10003
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AGENT: Please make check payable to GIAC or Value Guard and forward with
application to your general agent/dealer as listed below.
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1. Proposed Annuitant
Full M | |
name: | | | | | | | | ____________________ F | | Xxx.Xxx.Xx. | |-| |-| |
Mr. Mrs. Ms. Miss
Birth date_______________Place_______Age (last birthday)__Telephone( )_________
Month Day Year Area Code
Address___________________________City_____________State__________Zip___________
(Correspondence will be sent to this address unless Item 6 is completed or other
directions are given).
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2. Retirement Date
First day of (month and year) ____________
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3. Optional Income Plan at Maturity
Standard Annuity:
Life Annuity with 120 monthly payments guaranteed.
Other:____________________
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4. Contract Type (select one)
| | Single Payment: $_________________ (Minimum $3,000)
| | Flexible Payments:
Initial Payment $____________________ (Minimum $500)
Subsequent Payments of $____________ (Minimum $100)
are intended to be made | | Monthly | | Quarterly
| | Semi-annually | | Annually | | Bank Draft
(If payments will be remitted by an employer in connection with payroll
deductions or similar collection arrangements, the minimum payment (initial and
subsequent) is $50.)
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5. Payment Allocation (maximum of four)
__% The Value Line Cash Fund Code (15, 16)
__% The Value Line U.S. Government Securities Fund (13, 14)
__% The Value Line Income Fund (07, 08)
__% The Guardian Park Ave. Fund (03, 04)
__% The Value Line Fund (05, 06)
__% The Value Line Special Situations Fund (09, 10)
__% Value Line Leveraged Growth Investors (11, 12)
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100% Total
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6. Proposed Contract Owner (if other than Proposed Annuitant)
Full name _________________________________
Social Security No. or IRS Acct. No. | |-| |-| |
Address______________________
City__________________State__________Zip________
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7. Beneficiary
Primary____________________________________________
Relationship to Annuitant____________________
Contingent_________________________________________
Relationship to Annuitant____________________
If no designated Beneficiary is living at the Annuitants death, death benefits
are to be paid to | | Annuitant's estate | | Owner.
(Joint Beneficiaries will receive equally or survivor, unless otherwise
specified.)
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8. Tax Status (check appropriate box below)
| | b) The contract is being applied for under the Self-Employed Individuals
Tax Retirement Act (H.R. 10).
| | c) The contract is being applied for under a qualified Pension or
Profit-Sharing Plan.
| | d) This contract is being applied for as an Individual Retirement Annuity.
(Check here if SEP IRA | |)
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9. Will the Annuity Contract applied for replace any other insurance or annuity?
| |Yes | |No (If "Yes," explain)
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10. Please check box to receive the Statement of Additional Information | |
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11. Corrections and amendments (For Executive Office Use Only)
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IT IS REPRESENTED THAT all statements and answers made in this application
are full, complete and true to the best knowledge and belief of the Applicant(s)
and IT IS AGREED THAT all such statements and answers are adopted by and are
binding on the Applicant(s) and shall form the basis for any annuity contract
issued by the Company. IT IS AGREED THAT the annuity contract applied for shall
not take effect until the later of the date of issue of the contract and receipt
by the Company of the payment required thereon.
IT IS UNDERSTOOD AND AGREED THAT no person, except the President, a Vice
President or Secretary of the Company, has authority to determine whether any
contract shall be issued on the basis of the application, to waive or modify any
of the provisions of the application or any of the Company's requirements, to
bind the Company by any statement or promise pertaining to any contract issued
or to be issued on the basis of the application, or to accept any information or
representation not contained in the written application.
IT IS FURTHER UNDERSTOOD AND AGREED THAT annuity payments, cash values and
surrender values under any contract issued pursuant to this Application are
based upon assets allocated to THE GUARDIAN/VALUE SEPARATE ACCOUNT and are
variable in nature; thus, they are not guaranteed as to their dollar amount.
Receipt of a current variable annuity and applicable mutual funds prospectus is
hereby acknowledged.
Under penalties of perjury, I certify that (a) the number shown on this
form in Item 1 or 6 above is my correct taxpayer identification number and (b)
that I am not subject to backup withholding either because I have not been
notified that I am subject to backup withholding as a result of a failure to
report all interest or dividends, or the Internal Revenue Service has notified
me that I am no longer subject to backup withholding.
Dated at____________this___day of_______19__ __________________________________
(City/State) Signature of Proposed Annuitant
____________________________________________ __________________________________
Signature of Agent Signature of Proposed Owner (if
other than Proposed Annuitant) or
Payor
Payments and values provided by this contract are variable, may increase or
decrease, and are not guaranteed as to amount.
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AGENT: Do you have reason to believe that the contract applied for involves
replacement of any existing insurance or annuity contract?
| | Yes | | No (If "Yes," furnish full detail)
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G.A./DEALER: Mail Variable Annuity application and check to:
The Guardian Insurance & Annuity Company, Variable Annuity Administration, 0000
Xxxxxxx Xxxxx, Xxxxxxxxx, XX 00000
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FOR GENERAL AGENT/DEALER ONLY
G.A./Dealer Name__________________________________
Dealer Branch Office______________________________
City/State__________________Telephone( )_________
Area Code
Dealer Authorized Signature_______________________
Agent's Name Agent's
(as above)___________________________ Number______
(Last) Please Print (First)
Form No.IVA 1002 (1/88)
NOTE: FOR GUARDIAN AGENCY USE ONLY.
Section B
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Underwriting Information
(to be furnished by Soliciting Agent)
1. Information Relating to the Proposed Owner (not necessary if owner is a
corporation/institution)
a. Dependants_______________________
Spouse | | Yes | | No
Number of children under age 21 ____________
Other ___________________________________________
b. Occupation ______________________________________
c. U.S. Citizen | | Yes | | No
d. Annual Income (approx.) $
e. Personal Insurance in force (if with The Guardian, indicate)
Life--Individual $______________
Group $______________
Health--Disability Income (monthly) $______________
Hospital $______________
Major Medical $______________
Annuities--Variable $______________
Fixed $______________
f. Other Assets
Home $______________
Securities $______________
Other $______________
2. Other Pertinent Information
3. Were the terms and conditions of this contract thoroughly explained to the
applicant? | | Yes | | No
The Soliciting Agent represents that, to the best of his knowledge, the purchase
of this annuity contract does | | (attach explanation) does not | | involve
replacement of any existing insurance or annuity contract.
____________________________
Soliciting Agent's Signature
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Use this space to imprint Agency (or Broker-Dealer) and Agent codes in lieu of
filling in information in box at right.
Agency and Agent
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Commissions and production credit for this application are as follows:
(Please PRINT names in full.)
Agent__________________Code No.______
Agent__________________Code No.______
Agency (Broker-Dealer)_________ Code No._______
This application was actually solicited and written within my territory by a
duly authorized and licensed agent or broker of my Agency. (If otherwise, please
explain fully.)
___________________
Manager's Signature
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(FOR EXECUTIVE USE ONLY)
Signature and Approval of Approver____________________________
