a4c.htm







	
Allianz Life Insurance Company


	
of North America


	
Allianz [Index AdvantageSM] Variable Annuity Application


	  	  	  	  	
[Contract number: ___________________]









	
1.

	
Annuity registration


















	
Ownership is

	
[■  Individual/Joint

	
■  Qualified plan

	
■  Custodian

	
■ Trust (Include the date of trust in the name.)


	  	
■  UTMA/UGMA

	
■  Other]













	
Owner

	  
	
Individual Owner first name


 

	
MI


 

	
Last name


 

	
Jr., Sr., III


 

	  
	
Non-individual owner name (Attach Non- Individual Ownership form or Qualified Plan Acknowledgement form if applicable.)

	  
	
Social Security Number or Tax ID Number


 


	
Mailing address


 

	
Email address


 


	
City


 

	
State


 

	
ZIP code


 

	  	
Home telephone number


 


	
Street address (required if a P.O. Box was used for mailing address)


 


	
City


 

	
State


 

	
ZIP code


 

	  	
Cell phone number


 


	
Gender

	
■  Male

	
Date of birth (mm/dd/yyyy)

	
Are you a non-resident alien?


	  	
■  Female

	  	
■  Yes  (Attach W8 BEN)   ■  No













	
Joint Owner


	
First name


 

	
MI


 

	
Last name


 

	
Jr., Sr., III


 


	
Mailing address


 

	
Email address


 


	
City


 

	
State


 

	
ZIP code


 

	
Home telephone number


 


	
Gender

	
Date of birth (mm/dd/yyyy)

	
Are you a non-resident alien?


	
■  Male

	
■  Female

	  	
■  Yes  (Attach W8 BEN)   ■  No


	
Relationship to Owner


 

	
Social Security Number


 













	
Annuitant (Complete if different from Owner.)

	  	  	  
	
First name


 

	
MI


 

	
Last name


 

	
Jr., Sr., III


 


	
Mailing address


 

	
Email address


	
City


 

	
State

	
ZIP code

	
Home telephone number


	
Street address (required if a P.O. Box was used for mailing address)


 


	
City


 

	
State

	
ZIP code

	
Cell phone number


	
Gender

	
Social Security Number

	
Date of birth (mm/dd/yyyy)

	
Are you a non-resident alien?


	
■  Male

	
■  Female

	  	  	
■  Yes  (Attach W8 BEN)   ■  No


















	
F40538

	
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2.

	
Purchase Payment (This section must be completed.) Make check(s) payable to Allianz Life Insurance Company of North America (Allianz).









 


Include replacement forms if required


Method of Payment (Select all that apply)


 



	
■ Purchase Payment enclosed with application.     Amount enclosed: $________________________


	
Plan type at prior financial institution or contribution instructions:


	
Qualified

	
Roth (Qualified)


	
■ Traditional IRA

	
■ Contribution to Roth IRA for year ______________


	
■ SEP IRA

	
■ Roth IRA


	
■ Employer Contribution to SEP IRA

	
Nonqualified


	
■ Contribution to Traditional IRA for year_______

	
■ Other nonqualified payment


	
■ Qualified Plan (401(a) plan)

	  
	
■ Other ___________________________

	  











	

■ This Contract will be funded by a 1035 exchange, tax qualified transfer/rollover, CD transfer, or mutual fund redemption facilitated by Allianz. (Always include transfer forms)        Expected Amount: $___________________















	
■ This Contract will be funded by funds not requested or facilitated by Allianz.            Expected amount: $___________________
















	
Plan type at prior financial institution or contribution instructions:


	
Qualified

	
Nonqualified


	
■ Traditional IRA

	
■ Contribution to Roth IRA for year ______________


	
■ SEP IRA

	
■ Roth IRA


	
■ Employer Contribution to SEP IRA

	
Nonqualified


	
■ Contribution to Traditional IRA for year_______

	
■ 1035 Exchange


	
■ Qualified Plan (401(a) plan)

	
■ Other nonqualified payment


	
■ Other ___________________________

	  















	
3.

	
Plan specifics (This section must be completed to indicate how this Contract should be issued.)









These are the only available options.



	  	
Nonqualified:

	
■Nonqualified

	  	  	  	  
	  	
IRA:

	
■Traditional IRA

	
■

	
SEP IRA

	
■

	
Roth IRA

	
■

	
Roth IRA (conversion )

	  
	  	
Qualified plans:

	
■401(a) defined contriution plan    ■ 401(a) one person defined benefit plan

	  












	
4.

	
Allocation Option transfer and allocation authorization















	
■ Yes

	
Electronic Authorization - Allianz accepts allocation and transfer instructions by electronic notification. Electronic authorizations include requests received by telephone, fax, or our website. By checking “yes,” I am authorizing and directing Allianz to act on electronic instructions from me as well as my Financial Professional and/or anyone authorized by him/her to transfer and allocate Contract Value among the Allocation Options. If the box is not checked, electronic instructions will be accepted only from me, the Owner. Allianz will use reasonable procedures to confi rm that these electronic instructions are genuine. As long as these procedures are followed, the company and its offi cers, employees, representatives, and/or agents will be held harmless for any claim, liability, loss, or cost arising from unauthorized or fraudulent instructions. We reserve the right to deny any electronic transfer request or allocation instruction change, and to discontinue or modify our electronic instruction privileges at any time for any reason.


	  












	
5.

	
Replacement (This section must be completed.)















	
Do you have existing life insurance or annuity contracts? . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

	
■  Yes

	
■  No

	  
	
Will the annuity contract applied for replace or change existing contracts or policies?    . . . . .

	
■  Yes

	
■  No

	  










Notice to Financial Professional: If the Owner does have existing life insurance policies or annuity contracts and the application is being written in an NAIC replacement model state, Allianz requires that you must present and read to the Owner the Replacement of Life Insurance or Annuity form and return the notice, signed by both the Financial Professional and Owner, with the Application. Any required replacement forms must be signed and dated the date of the application or earlier.








	
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[6.

	
Index Effective Date (This section must be completed.)]









 



	
  

	
•  If chosen, the earliest Index Effective Date is the Issue Date of the Contract when the initial Purchase Payment, application, and requirements are received in good order.








	
  

	
•  If chosen, the deferred Index Effective Date is the fi rst Quarterly Anniversary. You can change the Index Effective Date prior to the first Quarterly Anniversary by contacting Allianz.








	
  

	
•  The Index Effective Date cannot be the 29th, 30th, or 31st of a month. If the Index Effective Date would occur on the 29th, 30th, or 31st of a month, we change the Index Effective Date to be the next available Business Day.








	
  

	
•  If the Index Effective Date is not the Issue Date, Purchase Payments allocated to the Index Option(s) will be placed in the AZL® Money Market Fund until the Index Effective Date.













	  	  	  
	  	
■ Earliest Index Effective Date OR ■ Deferred Index Effective Date

	  
	  	  	  












	
  

	
[7.Allocation Options]














 


•  Allocations must be in whole percentages (e.g. 33.3% or dollars are not permitted) which total 100%.



	
  

	
•  We place any Purchase Payments you allocate to an Index Option that we receive before the Index Effective Date in the [AZL® Money Market Fund] and these instructions become your future Purchase Payment allocation instructions. Then, on the Index Effective Date we transfer the amount you select to the Index Options(s) according to your instructions.








	
  

	
•  We only allow allocations (both Purchase Payments and transfers of Contract Value) into the Index Options on the Index Effective Date and on subsequent Index Anniversaries. • We only allow transfers of Index Option Value from the Index Options to the Variable Options on every [sixth Index Anniversary].








	
  

	
•  Please see the current prospectus for Allocation Option requirements and allocation of additional Purchase Payments received after the Index Effective Date.













	  	
Variable Options


Asset Allocation                                                                                                              Cash Equivalent

	  
	  	
____% AZL® MVP Balanced Index Strategy Fund                                                  ____% AZL® Money Market Fund

	  
	  	
____% AZL® MVP Growth Index Strategy Fund

	  
	  	  	  
	  	
Index Options

	  
	  	
Performance Strategy                                                                                                  Protection Strategy

	  
	  	
____% NASDAQ-100® Index Performance Strategy                                             ____% S&P 500® Index Protection Strategy

	  
	  	
____% Russell 2000® Index Performance Strategy

	  
	  	
____% S&P 500® Index Performance Strategy

	  
	  	  	  
	  	
Total of _______ % (must equal 100%)


 

	  










 [S&P® is a registered trademark of Standard & Poor’s Financial Services LLC(“S&P”) and Dow Jones® is a registered trademark of Dow Jones Trademark Holdings LLC (“Dow Jones”). These trademarks have been licensed for use by S&P Dow Jones Indices LLC and its affi liates. S&P® and S&P 500® are trademarks of S&P and Dow Jones®, Dow Jones Industrial AverageSM, DJIA and The Dow are trademarks of Dow Jones. These trademarks have been sublicensed for certain purposes by Allianz Life Insurance Company of North America (“Allianz”). The S&P 500 and Dow Jones Industrial Average (DJIA) are products of S&P Dow Jones Indices LLC and/or its affi liates and have been licensed for use by Allianz. Allianz products are not sponsored, endorsed, sold, or promoted by S&P Dow Jones Indices LLC, Dow Jones, S&P, or their respective affi liates and neither S&P Dow Jones Indices LLC, Dow Jones, S&P, or their respective affi liates make any representation regarding the advisability of investing in such product. The Nasdaq-100 Index® includes 100 of the largest domestic and international non-fi nancial securities listed on The Nasdaq Stock Market, based on capitalization.







The Nasdaq-100®, Nasdaq-100 Index®, Nasdaq®, and OMX® are registered trademarks of NASDAQ OMX Group, Inc. (which with its affi liates are the Corporations) and are licensed for use by Allianz Life Insurance Company of North America. The Contract(s) have not been passed on by the corporations as to their legality or suitability. The Contract(s) are not issued, endorsed, sold, or promoted by the Corporations. THE CORPORATIONS MAKE NO WARRANTIES AND BEAR NO LIABILITY WITH RESPECT TO THE CONTRACT(S).







The Russell 2000® is a trademark of Russell Investments and have been licensed for use by Allianz Life Insurance Company of North America. The Contract is not sponsored, endorsed, sold or promoted by Russell Investments and Russell Investments makes no representation regarding the advisability of investing in the Contract.







Not FDIC insured • May lose value • No bank or credit union guarantee • Not a deposit • Not insured by any federal government agency or NCUA/NCUSIF]








	
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[8.]

	
Beneficiary designation (If additional space is needed, attach a complete list signed and dated by Owner(s).)










	  	
■  Primary

	  	
Percentage

	
Relationship

	  	
Social Security Number or Tax ID Number

	
Phone Number

	  
	  	
■  Contingent

	  	  	  	  	  	  	  	  	  
	  	
First name

	
MI    Last Name

	  	
Date of birth (mm/dd/yy0

	
Gender

	  
	  	  	  	  	  	
■ Male    ■ Female

	  
	  	
Street Address

	  	
City   State

	
Zip Code

	  
	  	  	  	  	  	  
	  	
■  Primary

	  	
Percentage

	
Relationship

	  	
Social Security Number or Tax ID Number

	
Phone Number

	  
	  	
■  Contingent

	  	  	  	  	  	  	  	  	  
	  	
First name

	
MI    Last Name

	  	
Date of birth (mm/dd/yy0

	
Gender

	  
	  	  	  	  	  	
■ Male    ■ Female

	  
	  	
Street Address

	  	
City   State

	
Zip Code

	  
	  	  	  	  	  	  
	  	
■  Primary

	  	
Percentage

	
Relationship

	  	
Social Security Number or Tax ID Number

	
Phone Number

	  
	  	
■  Contingent

	  	  	  	  	  	  	  	  	  
	  	
First name

	
MI    Last Name

	  	
Date of birth (mm/dd/yy0

	
Gender

	  
	  	  	  	  	  	
■ Male    ■ Female

	  
	  	
Street Address

	  	
City   State

	
Zip Code

	  
	  	  	  	  	  	  











	  	
Non-individual Beneficiary information

	  
	  	
■ Qualified plan

	
■ Custodian   ■ Trust (Include the date of trust in the name.)

	
■ Charitable Trust

	
■ Other

	  
	  	
Name of plan, custodian, trust, etc:

	  	  
	  	
■  Primary

	  	
Percentage

	
Social Security Number or Tax ID Number           Phone Number

	  
	  	
■  Contingent

	  	  	  	  	  	  	  












	
[9].

	
Financial Professional














By signing below, the Financial Professional certifies to the following:








	
  

	
•

	
I am FINRA registered and state licensed for variable annuity contracts in all required jurisdictions; and I provided the Owner(s) with the most current prospectus.








	
  

	
•

	
The Owner statement regarding existing policies or annuity contracts is true and accurate to the best of my knowledge and belief.








	
  

	
•

	
The Owner statement as to whether or not an existing life insurance policy or annuity contract is being replaced is true and accurate to the best of my knowledge and belief.








	
  

	
•

	
I have provided the Owner with all appropriate disclosure and replacement requirements prior to the completion of this application.








	
  

	
•

	
If this is a replacement, include a copy of each disclosure statement and a list of companies involved.













	  	  	  	  	  
	
Financial Professional’s signature (primary contact)

	
B/D Rep. ID

	  
	  	  	  	  
	
Financial Professional’s first and last name (primary contact) (please print)

	  	
Percent split

	  
	  	  	  	  	  
	
Financial Professional’s signature (split case)

	
B/D Rep. ID

	  
	  	  	  	  
	
Financial Professional’s first and last name (please print) (split case)

	  	
Percent split

	  
	  	  	  	  	  
	
Financial Professional’s signature (split case)

	
B/D Rep. ID

	  
	  	  	  	  
	
Financial Professional’s first and last name (please print) (split case)

	  	
Percent split

	  
	  	  	  	  	  
	  	  	  	  	  
	
Financial Professional’s address

	
Registered Representative’s telephone number

	  
	  	  	  	  
	
Financial Professional’s preferred method of contact

	
■ Phone number

	
■ Email address

	  	  
	
Broker/dealer name (please print)

	
Authorized signature broker/dealer (if required)

	  	  
	  	  	  	  
	
Commission options


■ A    ■ B

	  	  	  











	
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[10].

	
Statement of Owner









The following states require Owners to read and acknowledge the statement for your state below.


 


Alabama, Arkansas, Louisiana, Massachusetts, Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefi t or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fi nes and confi nement in prison.







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, fi nes, 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.







Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person fi les an application for insurance or a 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, which is a crime.







New Mexico: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR A 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, WHICH IS A CRIME. THIS ACTIVITY SUBJECTS SUCH A PERSON TO CRIMINAL AND CIVIL PENALTIES.







Ohio: Any person who knowingly intends to defraud an insurance company, submits an application or fi les a statement of claim containing any false, incomplete, or misleading information, commits the crime of fraud and may be subject to criminal prosecution and civil penalties.







Oklahoma: WARNING: Any person who knowingly, and with


intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.







Washington: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.







 







 


 







 








	
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[10].

	
Statement of Owner (Continued)









 







 


 


By signing below, the Owner acknowledges the applicable statements mentioned above and 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 my financial needs and goals.







 



	
•

	
I understand that the Contract Value may increase or decrease depending on the investment results of the Allocation Options and that there is no guaranteed minimum Variable Account Value.








	
•

	
To the best of my knowledge and belief, all statements and answers in this application are complete and true.







 



	
•

	
No representative is authorized to modify this agreement or waive any Allianz rights or requirements.







 







 


For information on current Contract features, restrictions or charges please review with your Financial Professional.


 


The statement of additional information is available at [www.allianzlife.com].


 







 








	
_______________________________________________

	
______________________________________________________


	
Owner signature

	
Joint Owner signature


	  	  
	  	  
	
Signed at (City, State)

	
Signed date


	
 


Trust:_________________________________

	
as trustee of the :______________________________

	
____________________


	
Trustee’s signature

	
Trust name (printed)

	
Signed date


	  	  	  
	
Power-of Attorney:_______________________

	
by :_________________________________________

	
____________________


	
Contract owner’s name

	
Attorney-in-fact signature

	
Signed date


	  	  	  







	
  

	
Mailing information



















Please call Allianz with any questions at [800.624.0197].








	  	  	
Mailing information

	  	  	  
	  	  	  	  	  
	  	  	
Applications that HAVE a check attached

	  	  	  
	  	
Regular mail

	
Overnight, certified, or registered

	  	  	  
	  	
Allianz Life Insurance Company of North America

	
Allianz Life Insurance Company of North America

	  	  	  
	  	
NW 5989

	
NW 5989 Allianz

	  	  	  
	  	
PO Box 1450

	
1350 Energy Lane, Ste. 200

	  	  	  
	  	
Minneapolis, MN 55485-5989

	
St. Paul, MN 55108-5254

	  	  	  
	  	  	
Applications that DO NOT HAVE a check attached

	  	  	  
	  	
Regular mail

	
Overnight, certified, or registered

	  	  	  
	  	
Allianz Life Insurance Company of North America

	
Allianz Life Insurance Company of North America

	  	  	  
	  	
PO Box 561

	
5701 Golden Hills Drive

	  	  	  
	  	
Minneapolis, MN 55440-0561

	
Golden Valley, MN 55416-1297

	  	  	  
















	
F40538

	
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