Allianz Life Insurance Company of North America

  

  

  

  

  

  

  [Annuity Purchase Acknowledgement]

  Product:                                                                                                                                      Identification eNumber:

  Plan Type:

  

  

  

  

  Financial Professional Information

  Broker Dealer:

  Name(s):

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  Owner Information

  Name:                                                                                                                                      Date of birth:

  SSN/TIN:                                                                                                                                      Mobile Phone:

  Email address:

  Address:

  

  

  

  

  Joint Owner Information

  Name:                                                                                                                                      Date of birth:

  SSN/TIN:                                                                                                                                      Mobile Phone:

  Email address:

  Address:

  

  

  

  

  Annuitant Information

  Name:                                                                                                                                      Date of birth:

  SSN/TIN:                                                                                                                                      Mobile Phone:

  Email address:

  Address:

  
    
      	
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          Verification of Existing Policies or Contracts

        	 
	
           

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

        	
           

          Yes

        	
           

          No

        
	
           

          2. 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, Allianz Life Insurance Company of North America (Allianz) requires that you present and read to the Owner the Replacement of Life Insurance or Annuity form and return the notice, signed by both you and
    Owner, with the electronic request for purchase. Any required replacement forms must be signed and dated the date of the submission of the request or earlier.

  

  

  

  

  Product Features

  Contract Options:

  

  

  

  

  Death Benefit:

  

  

  

  

  Other Benefits:

  

  

  

  

  

  

  

  

  

  

  Beneficiary Designation

  Type                          Name                                                                                                                              Relationship                                        %

  
    
      	
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  Allocation Selection(s)

  
    
      	
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  Electronic Authorization

  [  YesNo

  Electronic Authorization – Allianz accepts allocation, transfer, Index Effective Date
    change instructions, Performance Lock instructions, and other administrative instructions by electronic notification. Electronic authorizations include, but are not limited to, requests received by telephone, fax, email, or on our website. By selecting
    “yes”, I am authorizing and directing Allianz to act on

  electronic instructions from my Financial Professional and/or any qualified person in
    the employ or administrative support of my Financial Professional to transfer and allocate Contract Value among the variable investment options and any other available allocations options and authorization for Index Effective Date changes and
    Performance Locks. Notwithstanding my authorization to Allianz, I understand

  I must approve the transactions recommended by my Financial Professional prior to submission to Allianz,
    unless I have separately and independently given my Financial Professional discretion over my contract. This authorization remains in effect until revoked by me.

  If I have multiple Financial Professionals as my current Financial Professional, they may act independently.
    If a Financial Professional is removed from my contract, any new Financial Professional added to my contract will have the same authority granted by this authorization. My Financial Professional shall maintain all required authorizations pursuant to
    Form ADV, power of attorney, agreement, or otherwise. If “yes” is not checked, electronic instructions will not be accepted from my Financial Professional or any qualified person in the employ or administrative support of my Financial Professional.
    Allianz will use reasonable procedures to confirm that these electronic instructions

  are valid. As long as these procedures are followed, the company and its officers,
    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, Index Effective Date change, Performance Lock, or
    allocation instruction change, and to discontinue or modify our electronic instruction privileges at any time for any reason.]

  

  

  Certification of Taxpayer Identification Number

  [If you are applying for this product and/or requesting payments as a U.S. Person, the IRS requires you to
    agree to the following statements.

  If you are not a U.S. Person, you are not eligible to apply for this product.

  

  

  Under penalties of perjury, I certify that:

  
    	
            1.

          	
            The Taxpayer Identification Number shown on this form is correct or I am waiting for a number to be issued to me.

          


  

  
    	
            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

          


  

  failure to report all interest or dividends, or

  
    	
            c.

          	
            The IRS has notified me that I am no longer subject to backup withholding.

          


  

  
    	
            3.

          	
            I am a U.S. person, and

          


  

  
    	
            4.

          	
            The Foreign Account Tax Compliance Act (FATCA) code(s) entered on this form (if any) indicating that I am exempt from
              FATCA reporting is correct.

          


  

  Check the box ONLY if the
    IRS has notified you that you are currently subject to backup withholding because you failed to report interest

  and dividends on your tax return.]

  
    
      	
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  Annuity Confirmation and Acknowledgement

  By signing below the owner(s) of the variable annuity contract described above hereby acknowledge and confirm
    that:

  
    	
            a.

          	
            My financial professional electronically submitted a request for the purchase of an Allianz variable annuity on my
              behalf and

          


  

  the information and details of the variable annuity set forth in this acknowledgement accurately reflect my intentions and
    request. Further, I confirm the Beneficiary Designation listed above.

  
    	
            b.

          	
            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.

          


  

  
    	
            c.

          	
            I understand that the variable annuity contract value may increase or decrease depending on the investment results
              of the variable investment options, and that the contract by itself provides no guaranteed amount of minimum contract value.

          


  

  

  

  [The IRS does not require your consent to any provision of this document other than the certifications required to avoid

  backup withholding.]

  

  

  

  

  

  

  Signed State

  

  

  

  

  Owner’s signature                                                                                                                              Date

  

  

  

  

  Joint Owner’s signature                                                                                                                              Date

  

  

  

  

  Annuitant’s signature                                                                                                                              Date

  

  

  

  

   as trustee of the                                                                                                                              
      Trustee’s signature  Trust Name

  

  

  Date

   as trustee of the                                                                                                                               Trustee’s signature  Trust Name

  

  

  Date

   as trustee of the                                                                                                                               Trustee’s signature  Trust Name

  

  

  Date

   as trustee of the                                                                                                                               Trustee’s signature  Trust Name

  

  

  Date

   by                                                                                                  

  Power-of-Attorney (Owner’s name)                                                                                                                  Attorney-in-fact’s signature

  

  

  Date

   by                                                                                                  

  Power-of-Attorney (Owner’s name)                                                                                                                  Attorney-in-fact’s signature

  

  

  Date

  
    
      	
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  Statement of Financial Professional

  
    	
            1.

          	
            The applicant has existing life insurance policies or annuity contracts?                                                                                                                                                                          YesNo

          


  

  
    	
            2.

          	
            This annuity contract will replace or change an existing policy or contract?                                                                                                                                                                          YesNo

          


  

  
    	
            3.

          	
            I have provided the applicant with all appropriate disclosure and replacement requirements prior to electronic
              submission.

          


  

  
    	
            4.

          	
            I hereby certify that I only used sales materials that were previously approved by Allianz in my presentation.

          


  

  
    	
            5.

          	
            I further certify that I left a copy of all sales material used during my presentation with the applicant.

          


  

  

  

  

  

  

  

  Financial Professional’s signature                                                                                                                              Date

  

  

  

  

  

  

  Financial Professional’s signature                                                                                                                              Date

  

  

  

  

  

  

  [For questions, contact Allianz at 800.624.0197]

  

  

  
    	
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