EX-4.2



 



 
  
 Application for Athene® Amplify ATHENE Single Purchase
Payment Index-Linked Deferred Annuity Athene Annuity and Life Company Mailing Address: PO Box 1555, Des Moines, IA 50306-1555 Overnight Address: 7700 Mills Civic Parkway, West Des Moines, IA 50266-3862 Customer Contact Center - Tel: 888 266 8489
Fax: 866 709 3922 FINANCIAL PROFESSIONAL CODE & NAME: APP SIGNED STATE: DISTRIBUTOR LICENSE ID #: www.atheneannuity.com Exhibit 4.2 1. PRODUCT Rider(s) Product Name 2. OWNER Individual or Trustee First Name M. I. Last Name Suffix Trust or
Company Name Social Security Number/Tax ID Date of Birth (MM/DD/YY) Gender M F Relationship to Proposed Annuitant: Spouse Other: Street Address (Required - No PO Box) City State Zip Country Mailing Address (Optional) City State Zip Country US
Citizen Yes No Country of Citizenship Email Phone Note: If the proposed owner(s) is not a natural person, for example a trust, a corporation or an association, then additional documentation will be required to establish the entity’s legal
identity and who has authority to legally act on behalf of the entity. If contingent owner exists, include the Contingent Owner Form. 3. JOINT OWNER Not applicable to qualified contracts or to those not owned by natural persons First Name M. I. Last
Name Suffix Social Security Number/Tax ID Date of Birth (MM/DD/YY) Gender M F Relationship to Proposed Annuitant: Spouse Other: Street Address (Required - No PO Box) City State Zip Country Mailing Address (Optional) City State Zip Country US Citizen
Yes No Country of Citizenship Email Phone 4. REPLACEMENT This section must be completed No Do you have an existing life insurance policy or annuity contract? No Will this annuity change or replace an existing life insurance policy or annuity
contract? Yes Yes 5. ANNUITANT (complete if different from owner) First Name M. I. Last Name Suffix Social Security Number Date of Birth (MM/DD/YY) Gender M F Phone Number Street Address (Required - No PO Box) City State Zip Country Page 1 of 1
ICC18 21497 







 



 
  
 Application for Athene® Amplify ATHENE Single Purchase
Payment Index-Linked Deferred Annuity www.atheneannuity.com 6. JOINT ANNUITANT Not applicable to non-spouse or qualified contracts First Name M. I. Last Name Suffix Social Security Number Date of Birth (MM/DD/YY) Gender M F Phone Number Street
Address (Required - No PO Box) City State Zip Country 7. TRUSTED CONTACT PERSON INFORMATION (Optional) By choosing to provide information about a trusted contact person, you authorize us to contact the trusted contact person listed below and
disclose information about your account to that person in the following circumstances: to address possible financial exploitation, to confirm the specifics of your current contact information, health status, or the identity of any legal guardian,
executor, trustee or holder of a power of attorney, or as otherwise permitted by FINRA Rule 2165 (Financial Exploitation of Specified Adults). First Name M. I. Last Name Suffix Street Address (Required - No PO Box) City State Zip Country Email
Relationship to Owner/Joint Owner Work Phone ( ) - Home Phone ( ) - Mobile Phone ( ) - 8. BENEFICIARIES • Proceeds will be divided equally if no percentages are listed. All beneficiaries must be living/existing at the time of Application. The
sum of the percentages for Primary and Contingent Beneficiaries, respectively, must total 100%. A contingent beneficiary will receive the proceeds if the primary beneficiary dies prior to the payment of any proceeds. • If the beneficiary is a
trust, include the name and trust creation date on the Beneficiary name line. • Please provide Social Security/Tax Identification Numbers to expedite future Death Claim processing. • List additional beneficiaries on a separate page. Owner
must sign, date and include required information. Individual, Trust or Company Name Primary Contingent Percentage % Phone Number SSN/TIN Date of Birth(MM/DD/YY) Gender M F Relationship to Proposed Annuitant: Address City State Zip Country
Individual, Trust or Company Name Primary Contingent Percentage % Phone Number SSN/TIN Date of Birth(MM/DD/YY) Gender M F Relationship to Proposed Annuitant Address City State Zip Country ICC18 21497 Page 2 of 2 







 



 
  
 Application for Athene® Amplify ATHENE Single Purchase
Payment Index-Linked Deferred Annuity www.atheneannuity.com 8. BENEFICIARIES (continued) Individual, Trust or Company Name Primary Contingent Percentage % Phone Number SSN/TIN Date of Birth(MM/DD/YY) Gender M F Relationship to Proposed Annuitant:
Address City State Zip Country Individual, Trust or Company Name Primary Contingent Percentage % Phone Number SSN/TIN Date of Birth(MM/DD/YY) Gender M F Relationship to Proposed Annuitant: Address City State Zip Country 9. ANNUITY TYPE Select one
option to indicate how this contract should beissued Non-Qualified IRA (select only one): Traditional Roth SEP Inherited IRA (select only one): Traditional Roth For Qualified options, select all that apply: Contribution Year Direct Rollover within
60 if inherited IRA selected above, complete for decedent: Decedent Name: Relationship to Proposed Annuitant: Spouse Other: Date of Birth (MM/DD/YY) Date of Death (MM/DD/YY) 1Please complete and submit the applicable Request for Funds Form or ACORD
951 form, for each account to be transferred into this contract. 2I understand that, except in the case of a Roth Conversion, I can make only one rollover from an IRA (including a Traditional IRA, Roth IRA, or SEP IRA) to an IRA in any 1-year
period, regardless of the number of IRAs I own. 10. PREMIUMS Make all checks payable to Athene Annuity and Life Company; estimate total transfer amounts New purchase $ Transfer/Rollover $ Internal Transfer Existing Athene Contract Number(s) $ Total
Anticipated P remium $ 11. ELECTRONIC DOCUMENT DELIVERY By providing your email address in Section 2 and signing the application, you will receive information about electronic document delivery. After your annuity is issued, you will receive an
email with a link to our website to authorize electronic document delivery. Until your authorization for electronic delivery has been finalized, you will receive all correspondence via U.S. Mail. While electronic delivery may significantly reduce
the amount of mail sent to you, certain documents and service-related correspondence will continue to be sent via U.S. Mail. 







 



 
  
 Application for Athene® Amplify Single Purchase Payment
Index-Linked DeferredATHENE www.atheneannuity.co 12. AGREEMENTS AND SIGNATURES The Owner agrees that all statements and answers to questions in this application are true to the best of my knowledge and belief. All states: any person who knowingly
presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under statelaw. I have received a copy oftheprospectus. Yes No IRS CERTIFICATION Under penalties of perjury, I certify that: 1.
The Social Security Number or Taxpayer Identification Number shown on this form is correct (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I
have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (as defined in the General Instructions of IRS Form W-9), and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Exemption from FATCA reporting
code (if any): . (FATCA reporting codes can be found in the General Instructions on IRS Form W-9.) If you are only submitting this form for an account you hold in the United States, you may leave this field blank. Certification Instructions: You
must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. The internal revenue Service does not require your
consent to any provisions of this document other than the certifications required to avoid backup withholding. Signed at City State On Date Owner Signature X Joint Owner Signature (if applicable) X Annuitant Signature (if other than Owner) X Joint
Annuitant Signature (if applicable) X ICC18 21497 Page 4 of 4 







 



 
  
 Application for Athene® Amplify ATHENE Single Purchase
Payment Index-Linked Deferred ATHENE www.atheneannuity.co 13. FINANCIAL PROFESSIONAL USEONLY 1. Yes No Does the applicant have an existing life insurance policy or annuity contract? 2. Yes No Will this annuity replace or change an existing life
insurance policy or annuity contract? If (Yes) to either question, and if required by state regulation, replacement forms must accompany this application. 3. Yes No Is any participant on this contract or a dependent family member of a participant on
this contract an active duty (full-time) service member (officer or enlisted) of the United States Armed Forces (Army, Navy, Air Force, Marine Corps, or Coast Guard)? If Yes, please complete Military Disclosure Form 18257. By signing below, I
certify I have truly and accurately recorded on this application the information provided by the applicant. I certify that only company approved sales materials were used and that copies of such materials were 1) left with the client and 2) retained
in my files. I certify any required disclosure material has been presented to the applicant. I have not made any statements which differ from this material nor have I made any promises about the future expected values of this Contract. Complete the
following section for any additional producers and indicate the split percentages. Producer Name Producer Code Producer Phone Number/Email Address Split % - must Equal 100% Producer Signature Date Signed Producer Name (print please) Producer Phone
Number Producer Email Commission Option 1 Commission Option 2 Commission Option 3 ICC18 21497 Page 5 of 5 







 



 
  
 Athene¢Amplify ATHENE www.atheneannuity.co Athene
Life Insurance Company Mailing Address: PO Box 1555, Des Moines, IA 50306-1555 Overnight Address: 7700 Mills Civic Parkway, West Des Moines, IA 50266-3862 Customer Contact Center - Tel: 888 266 8489 Fax: 866 709 3922 Policy Number: (if available)
INSTRUCTIONS This form is required to establish the Segment Allocations and must accompany the Application for Athene Amplify. 1. OWNERINFORMATION Individual or Trustee First Name M. I. Last Name Suffix Trust or Company Name (Required for
Non-Natural Owners) 2. SEGMENTALLOCATION Please select the Segment Options you would like your Purchase Payment allocated to by indicating the percentage each Segment Option should receive. Allocations must be made in whole (1%) increments and total
100%. Buffer Segment Options Segment Term Index/ticker Protection Level Index Allocation Percentage Allocation 1-year S&P (SPX) 10% 100% % Russell 2000 (RUT) 10% 100% % MSCI EAFE (EFA) 10% 100% % 2-year S&P (SPX) 10% 100% % Russell 2000
(RUT) 10% 100% % MSCI EAFE (EFA) 10% 100% % 6-year S&P (SPX) 20% 100% % Performance Blend (SPX, RUT, EFA)* 10% 50%/30%/20% % *The Performance Blend is a weighted average where 50% of the Interest Credit would reflect the return of the best
performing Index on the Segment End Date, 30% of the Interest Credit would reflect the second best performing Index on the Segment End Date and 20% of the Interest Credit would reflect the lowest performing Index on the Index EndDate. Floor Segment
Options Segment Term Index/ticker Protection Level Index Allocation Percentage Allocation 1-year S&P (SPX) 10% 100% % Russell 2000 (RUT) 10% 100% % MSCI EAFE (EFA) 10% 100% % 2-year S&P (SPX) 10% 100% % Russell 2000 (RUT) 10% 100% % MSCI
EAFE (EFA) 10% 100% % Fixed Segment Options Segment Term Index/ticker Protection Level Allocation 1-year N/A N/A Total (must equal 100%): % Page 1 of 2 







 



 
  
 Athene® Amplify ATHENE www.atheneauunity.co Segment
Allocation 3. OPTIONAL AUTOMATIC REBALANCING You have the option to establish Automatic Rebalancing, based on the allocations you selected in Section 2, Segment Allocation. If you choose this option, we will automatically transfer your Segment
Values among your Segment Options at each Segment End Date within the first six Contract Years so that you maintain your chosen Segment Allocations. Do you elect to establish Optional Automatic Rebalancing among the Segment Allocations selected in
Section 2? Yes No 4. SIGNATURE(S) Owner Signature X Date Joint Owner Signature (if applicable) X Date Page 2 of 2