USAllianz Rewards
A Flexible Premium Variable Annuity
Issued by Allianz Life Insurance Company of North America DA__________
______________________________________________________________________________
1.CONTRACT OWNER Must be age 80 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 80 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 80 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 forms.
___ 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)
___Roth IRA Conversion ___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
include the appropriate forms).
______________________________________________________________________________
8.PURCHASE PAYMENT ALLOCATION
You may elect to have 100% of your bonus amount allocated to the USAllianz
VIP Money Market Investment Option.
____ USAllianz VIP Money Market (If you do not check this box, your bonus
amount will be allocated as indicated below on all future payments until you
notify us of a change.
You may select up to 10 Investment Options. Use whole percentages. The
allocations you indicate below will become your allocations on all future
payments until you notify us of a change.
___%AIM V.I. Capital Appreciation ___%PIMCO VIT High Yield Bond
___%AIM V.I. Growth ___%PIMCO VIT Stocks PLUS Growth
___%AIM V.I. International Equity and Income
___%AIM V.I. Value ___% PIMCO VIT Total Return Bond
___%Xxxxx American Growth ___%Seligman Global Technology
___%Xxxxx American Leveraged All Cap ___%Seligman Small-Cap Value
___%Xxxxx American Midcap Growth
___%Xxxxx American Small Capitalization ___%Xxxxxxxxx Developing Markets
Equity
___%Xxxxxxxxx Global Growth
___%Xxxxx VA Financial ___%Xxxxxxxxx Pacific Growth
___%Xxxxx VA Real Estate
___%Xxxxx VA Value ___%USAllianz VIP Diversified Assets
___%USAllianz VIP Fixed Income
___%Franklin Growth and Income ___%USAllianz VIP Global Opportunities
___%Franklin Rising Dividends Securities___%USAllianz VIP Growth
___%Franklin Small Cap ___%USAllianz VIP Money Market
___%Franklin U.S. Government
___%Xxx Xxxxxx LIT Enterprise
___%X.X. Xxxxxx International ___%Xxx Xxxxxx LIT Growth and Income
Opportunities
___%X.X. Xxxxxx U.S. Disciplined Equity ___%Allianz Life Fixed Account
___%Mutual Discovery Securities ___TOTAL (Must equal 100%)
___%Mutual Shares Securities
___%Xxxxxxxxxxx VA Global Securities
___%Xxxxxxxxxxx VA High Income
___%Xxxxxxxxxxx VA Main Street Growth &
Income
You will be given any gains or losses on the bonus amounts allocated to this
Contract. The bonus amounts will be allocated the same as your Purchase
Payments.
______________________________________________________________________________
9. Guaranteed Minimum Protection Benefit Election
Traditional Guaranteed Minimum Protection Benefit
USAllianz Rewards automatically includes a basic Guaranteed Minimum
Death Benefit that is applicable to contracts owned for the benefit of an
individual.
The Traditional Guaranteed Minimum Death Benefit provides a death benefit
equal to the greater of: 1) Contract Value;
2) Purchase Payments less proportionate surrenders
This is the Contract default option. If you do not choose the option below,
this will be the Protection Benefit on the Contract.
________________________________________________________________________________
Enhanced Guaranteed Minimum Protection Benefit (Optional)
You can choose the Enhanced Guaranteed Minimum Death Benefit. An additional
charge is assessed to the Contract Owner for this option. Upon making your
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 Enhanced Guaranteed Minimum Death Benefit provides a death benefit equal
to the greater of:
1)Contract Value;
2)Purchase Payments less proportionate surrenders;
3)The greatest Contract Anniversary adjusted by subsequent premiums less
proportionate surrenders up to the Contract Owner's 81st birthday.
______________________________________________________________________________
10. INCOME DATE
Selected Income Date ___- 01 -___ The Income Date (Annuitization Date) may be
no earlier than three 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 Investment Options and to disburse partial surrenders.
For partial surrenders Allianz Life's sole responsibility is to send a check 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.
___ 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 Investment Options. 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.
______________________________________________________________________________
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 Investment Options may increase or decrease depending
on the contract's investment results, and that no minimum cash value is
guaranteed on the variable Investment Options. 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 (Please Registered Representative Name (Please
Print) 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 (circle one)
______________________________________________________________________________
14.MAIL APPLICATIONS TO
For Regular Mail For Overnight Delivery
Allianz Life-USAllianz Service Center Allianz Life-USAllianz Service Center
c/o PNC Bank c/o PNC Bank
Box 824240 Attn: Box 4240
Philadelphia, PA 19182-0000 Xxxxx 00 xxx Xxxx Xxxx Xxxxx
Xxxxxxxxxx, XX 00000-0000
______________________________________________________________________________
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).
F40327
