Document:

Allianz Life Insurance Company of North America

  

  

  

  

  

  

  [Allianz Index Advantage+SM] Variable Annuity Application

  [Contract number                                                                          ]

  
    	
            1.

          	
            Annuity Registration

          

  

  Ownership is: [                                                            Individual/Joint                                                          Qualified plan                              Custodian                          Trust (Include the date of the trust in the name.)

  Religious organtization (e.g., Church) (subject to approval)                                                                                                                              Corporation (e.g., LLC or Nonprofit) (subject to approval) Endowment or Foundation (subject to approval)  Partnership or limited partnership
      (subject to approval)]

  

  

  
    	
            a.

          	
            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.)

                                                                                  [Gender:                Male              Female]
      Social Security Number/Tax Identification Number  Date of birth (mm/dd/yyyy)

  

  

  	
          Are you a U.S. Citizen?

        	
          Yes (If yes, then proceed to address.)

        	
          No (If no, then proceed to next question.)

        
	
           

          Are you a non-resident alien?

        	
           

          Yes (If yes, then you are not eligible for this product.)

        	 
	 	
           

          No (If no, then proceed to Country of Citizenship.)

        	 

  Country of Citizenship                                                                                                                

  

  

  	
           

          Street address (required if a PO Box is being used for mailing address)

        	 	
           

          City

        	 	
           

          State

        	 	
           

          ZIP code

        
	
           

          Mailing address

        	 	
           

          City

        	 	
           

          State

        	 	
           

          ZIP code

        

  

  

  Email address                                                                                                            Cell phone number                                                    Home
      phone number

  

  

  
    	
            b.

          	
            Joint Owner (Must be legally recognized spouses.)

          

  

  

  

  First name                                                                                MI                          Last name                                                                                Jr.,
      Sr., III

                                                                                  [Gender:                Male              Female]
      Social Security Number/Tax Identification Number  Date of birth (mm/dd/yyyy)

  Relationship to Owner:                                                                                                                            Spouse under a legally recognized
      marriage  Other  

  Are you a U.S. Citizen?                                                      Yes
        (If yes, then proceed to address.)                                                                                          No (If no, then proceed to next
      question.) Are you a non-resident alien?  Yes (If yes, then you are not eligible for this product.)

  No (If no, then proceed to Country of Citizenship.) Country of Citizenship  

  

  

  	
           

          Street address (required if a PO Box is being used for mailing address)

        	 	
           

          City

        	 	
           

          State

        	 	
           

          ZIP code

        
	
           

          Mailing address

        	 	
           

          City

        	 	
           

          State

        	 	
           

          ZIP code

        

  

  

  Email address                                                                                                            Cell phone number                                                    Home
      phone number

  
    
      	
              IXA-APP-04

            

      	
              Page [1 of ]

            

      	
              [(5/2023)]

            

      

      

    

    
      

    

  

  

  

  
    	
            1.

          	
            Annuity Registration (continued)

          

  

  
    	
            c.

          	
            Annuitant (complete if different from Owner)

          

  

  

  

  First name                                                                                MI                          Last name                                                                                Jr.,
      Sr., III

                                                                                  [Gender:                Male              Female]
      Social Security Number/Tax Identification Number  Date of birth (mm/dd/yyyy)

  Relationship of Annuitant to Owner:                                                                                                                                                  Spouse
      under a legally recognized marriage  Other  

  Is the Annuitant a U.S. Citizen?                                                                Yes (If yes, then proceed to address.)                                                                              No (If no, then proceed to next
      question.) Is the Annuitant a non-resident alien?  Yes (If yes, then the Annuitant is not eligible for this product.)

  No (If no, then proceed to Country of Citizenship.) Country of Citizenship  

  

  

  	
           

          Street address (required if a PO Box is being used for mailing address)

        	 	
           

          City

        	 	
           

          State

        	 	
           

          ZIP code

        
	
           

          Mailing address

        	 	
           

          City

        	 	
           

          State

        	 	
           

          ZIP code

        

  

  

  Email address                                                                                                            Cell phone number                                                    Home
      phone number

  

  

  

  

  

  

  
    	
            2.

          	
            Optional Death Benefit

          

  

  [  Maximum Anniversary Value Death Benefit (Carries an additional charge)]

  

  

  
    	
            3.

          	
            Index Effective Date (This section must be completed.)

          

  

  
    	
            •

          	
            The Index Effective Date can be any Business Day from the Issue Date up to and including the first Quarterly Contract
              Anniversary. However, it 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, or on a day that is not a
              Business Day, 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 will be placed in the [AZL®
              Government Money Market Fund] until the Index Effective Date.

          

  

  	

        	[	
          Earliest Index Effective Date – 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. This option is not designed to accommodate multiple
            Purchase Payments (e.g., 1035 exchanges, tax qualified transfers/rollovers, etc.) expected before the first Quarterly Contract Anniversary.

        

  OR

  Deferred Index Effective Date – If chosen, the deferred Index Effective Date is the first Quarterly Contract Anniversary. You can change the Index Effective Date prior to the first Quarterly Contract Anniversary by
    contacting Allianz Life Insurance Company of North

  America (Allianz). This option is designed to accommodate multiple Purchase Payments expected before the first Quarterly
    Contract

  Anniversary.]

  
    
      	
              IXA-APP-04

            

      	
              Page [2 of ]

            

      	
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            4.

          	
            Index Options

          

  

  
    	
            •

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

          

  

  
    	
            •

          	
            If Purchase Payments are received before the Index Effective Date the following will occur:

          

  

  
    	
            -

          	
            Your Purchase Payments will be placed in the [AZL® Government Money Market Fund].

          

  

  
    	
            -

          	
            Then, on the Index Effective Date we will rebalance your Contract Value among your selected Allocation Options below.

          

  

  
    	
            •

          	
            [If additional Purchase Payments are received after the Index Effective Date then your Purchase Payment will be placed
              in the [AZL® Government Money Market Fund] until the next Index Anniversary.]

          

  

  
    	
            •

          	
            [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.]

          

  

  
    	
            •

          	
            Please see the current prospectus for allocation requirements.

          

  

  

  

  [Index Options

   6-Year Term                                                                                                                                                                                                                     Index Performance Strategy

  % S&P 500® Index with a 10% buffer                                                                                                              % Russell 2000® Index with a 10% buffer

   3-Year Term                                                                                                                                                                                                                     Index Performance Strategy

  % S&P 500® Index with a 10% buffer                                                                                                            % S&P 500® Index with a 20% buffer

  % Russell 2000® Index with a 10% buffer                                                                                                            % Russell 2000® Index with a 20% buffer

   1-Year Term                                                                                                                                                                                                                     Index Performance Strategy  Index Guard Strategy

  % S&P 500® Index with a 10% buffer                                                                                                            % S&P 500® Index with a -10% floor

  % Russell 2000® Index with a 10% buffer                                                                                                            % Russell 2000® Index with a -10% floor

  % Nasdaq-100® Index with a 10% buffer                                                                                                            % Nasdaq-100® Index with a -10% floor

  % iShares® MSCI Emerging Markets ETF with a 10% buffer                                                                                                                                        % iShares® MSCI Emerging Markets ETF with a -10% floor

  % EURO STOXX 50® with a 10% buffer                                                                                                            % EURO STOXX 50® with a -10% floor

  

  

  Index Precision Strategy                                                                                                            Index
      Protection Strategy with Trigger *

  % S&P 500® Index with a 10% buffer                                                                                                            % S&P 500® Index

  % Russell 2000® Index with a 10% buffer                                                                                                            % Russell 2000® Index

  % Nasdaq-100® Index with a 10% buffer                                                                                                            % Nasdaq-100® Index

  % iShares® MSCI Emerging Markets ETF with a 10% buffer                                                                                                                                        % iShares® MSCI Emerging Markets ETF

  % EURO STOXX 50® with a 10% buffer                                                                                                            % EURO STOXX 50®

  

  

  

  

  

  

  Total of                           % (must equal 100%)

  

  

  * 100% protection against loss]

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

        
	
           

          Primary Contingent

        	
           

          Percentage

        	
           

          Relationship

        	
           

          Social Security Number/TIN 1

        	
           

          Phone number

        
	
           

          Individual first name

        	
           

          MI

        	
           

          Last name

        	
           

          Date of birth (mm/dd/yyyy)1

        	
           

          [Gender

          Male              Female]

        
	
           

          Qualified plan                                                  Custodian                                                                          Trust (Include the date of trust in the
              name.)  Charitable Trust Non-individual Beneficiary name

        	
           

          Email

        
	
           

          Street address

        	
           

          City

        	
           

          State

        	
           

          ZIP code

        
	 
	
           

          Primary Contingent

        	
           

          Percentage

        	
           

          Relationship

        	
           

          Social Security Number/TIN 1

        	
           

          Phone number

        
	
           

          Individual first name

        	
           

          MI

        	
           

          Last name

        	
           

          Date of birth (mm/dd/yyyy)1

        	
           

          [Gender

          Male              Female]

        
	
           

          Qualified plan                                                  Custodian                                                                          Trust (Include the date of trust in the
              name.)  Charitable Trust Non-individual Beneficiary name

        	
           

          Email

        
	
           

          Street address

        	
           

          City

        	
           

          State

        	
           

          ZIP code

        
	 
	
           

          Primary Contingent

        	
           

          Percentage

        	
           

          Relationship

        	
           

          Social Security Number/TIN 1

        	
           

          Phone number

        
	
           

          Individual first name

        	
           

          MI

        	
           

          Last name

        	
           

          Date of birth (mm/dd/yyyy)1

        	
           

          [Gender

          Male              Female]

        
	
           

          Qualified plan                                                  Custodian                                                                          Trust (Include the date of trust in the
              name.)  Charitable Trust Non-individual Beneficiary name

        	
           

          Email

        
	
           

          Street address

        	
           

          City

        	
           

          State

        	
           

          ZIP code

        

  1Required if spouse

  
    
      	
              IXA-APP-04

            

      	
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            6. 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.                                                                                                                                                  Total 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                                                                                      Inherited IRA (Qualified)

    Contribution to Traditional IRA for year                                                                                                      NOTE: Inherited IRA contracts are not available for this product

  

  SIMPLE IRA

  Qualified Plan (401(a) plan)

  401(k)

  401(k) Roth

  Inherited IRA Inherited Roth IRA Inherited SEP IRA Inherited SIMPLE IRA

  
    457(b) Plan                                                                                      Nonqualified

    HR10/Keogh                                                                                          Other nonqualified payment]

    Profit Sharing Plan

    Money Purchase Plan

    One Person Defined Benefit Plan

    Pension TSA (403b)

    Other                                                    ]

    

    

    This Contract will be funded by money requested or facilitated by Allianz with transfer forms included.

    If 1035 exchange or tax-qualified transfer, complete the [Authorization to Transfer Funds form].

    Total expected amount: $                                                                    

    

    

    This Contract will be funded by money requested or facilitated by Allianz when transfer forms are received
      at a later date.

    If 1035 exchange or tax-qualified transfer, complete the [Authorization to Transfer Funds form].

    Total expected amount: $                                                                    

    

    

    This Contract will be funded by money not requested or facilitated by Allianz.                                                                                                                                                                                              Total expected amount: $  

    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                                                                                      Inherited IRA (Qualified)

    Contribution to Traditional IRA for year                                                                                                      NOTE: Inherited IRA contracts are not available for this product SIMPLE IRA  Inherited
        IRA

    Qualified Plan (401(a) plan)                                                                                          Inherited Roth IRA

    401(k)                                                                                          Inherited SEP IRA

    401(k) Roth                                                                                          Inherited SIMPLE IRA

    457(b) Plan                                                                                      Nonqualified

    HR10/Keogh                                                                                          Other nonqualified payment]

    Profit Sharing Plan

    Money Purchase Plan

    One Person Defined Benefit Plan

    Pension TSA (403b)

    Other                                                    ]

  

  
    
      	
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            7.

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

          

    

    

    	
            [Nonqualified:

          	
            Nonqualified

          	 
	
             

            Qualified plans:

          	
             

            401(k)

          	
             

            HR10/Keogh

          	
             

            Profit Sharing Plan

          	
             

            Money Purchase Pension Plan

          

  

  

  

  

  

  IRA:

  One Person Defined Pension Plan

  Traditional IRA                                      SEP IRA                          Roth IRA  Roth IRA (conversion of existing IRA)]

  
    

    

    

    

    	
            8.

          	
            Replacement (This section must be completed.)

          

    Yes        No  Do you have existing life insurance policies or annuity contracts?

    Yes        No  Will the annuity contract applied for replace or change existing policies or contracts?

    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. Replacement forms must be signed and dated on or before the application signed date.

    

    

    	
            9.

          	
            Electronic Authorization

          

    	

          	[	
            Yes 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.]

    

    

    	
            10.

          	
            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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            11.

          	
            Financial Professional

          

  

  Notice to Financial Professional: Applicable product training must be completed for the
    state for which this sale occurred.

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

          

  

  
    	
            •

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

          

  

  
    	
            •

          	
            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)

        	
           

          B/D Rep. ID

        
	
           

          First and last name (please print)

        	
           

          Percent split

        
	
           

          Address

        	
           

          Telephone number

        
	
           

          Email

        	
           

          Cell phone number

        
	
           

          Financial Professional’s signature (Secondary)

        	
           

          B/D Rep. ID

        
	
           

          First and last name (please print)

        	
           

          Percent split

        
	
           

          Email

        	
           

          Cell phone number

        

  Broker/dealer name (please print)

  

  

  Authorized signature broker/dealer (if required)

  

  

  Commission options (please check one) A  B  C  D

  (Some commission options may not be available through your Broker/Dealer. Please contact your Broker/Dealer to confirm which

  	
          ]

        

  options are available.)

  

  

  
    
      	
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            12.

          	
            Agreements and Signatures

          

  

  

  

  By signing below, I, the Owner, understand and agree 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.

          

  

  
    	
            •

          	
            If this Contract is being funded by an indirect rollover, I have complied with the requirement that only one rollover
              is permitted within a one year period from all of the IRAs I own.

          

  

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

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

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

  backup withholding.]

  As the authorized signer, please sign your name and date below in the appropriate space or we will not be able
    to process your request.

  

  

  

  

  Signed at (City and State)

  

  

  

  Owner’s signature:                                                                                                                                               Date:

  MM/DD/YYYY

  

  

  

  Joint Owner’s signature:                                                                                                                                               Date:

  MM/DD/YYYY

  

  

  Alternate signatures, if applicable

  

  

  Trust:                                                             as trustee of the:                                                                                     Date:                                                            

  TRUSTEE’S SIGNATURE                                                                                TRUST NAME
        (PRINTED)                                                                    MM/DD/YYYY

  

  

  Trust:                                                             as trustee of the:                                                                                       Date:                                                          

  TRUSTEE’S SIGNATURE                                                                                    TRUST NAME
        (PRINTED)                                                                MM/DD/YYYY

  

  

  Trust:                                                             as trustee of the:                                                                                       Date:                                                          

  TRUSTEE’S SIGNATURE                                                                                    TRUST NAME
        (PRINTED)                                                                MM/DD/YYYY

  

  

  

  

  Power of attorney:                                                                                             by:                                                     Date:                                                            

  OWNER’S NAME (PRINTED)                                                            ATTORNEY IN FACT’S
        SIGNATURE(S)                                                                              MM/DD/YYYY

  
    
      	
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              IXA-APP-04

            

      	
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  [The S&P 500® Index is comprised of 500 stocks representing major U.S. industrial sectors.

  S&P® is a registered trademark of Standard & Poor’s Financial
    Services LLC (“S&P”). This trademark has been licensed for use by S&P Dow Jones Indices LLC. S&P marks are trademarks of S&P. These trademarks have been sublicensed for certain purposes by Allianz Life Insurance Company of North America
    (“Allianz”). The S&P 500® Index (“the Index”) is a product of S&P Dow Jones Indices LLC and/or its affiliates 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 any of their respective affiliates (collectively, “S&P Dow Jones Indices”). S&P Dow Jones Indices make no representation or warranty, express or implied, to the owners of the Allianz products or any member of
    the public regarding the advisability of investments generally or in Allianz products particularly or the ability of the Index and Average to track general market performance. S&P Dow Jones Indices’ only relationship to Allianz with respect to the
    Index and Average is the licensing of the Index and Average and certain trademarks, service marks, and/or trade names of S&P Dow Jones Indices and/or its third-party licensors. The Index and Average are determined, composed, and calculated by
    S&P Dow Jones Indices without regard to Allianz or the products. S&P Dow Jones Indices have no obligation to take the needs of Allianz or the owners of the products into consideration in determining, composing, or calculating the Index and
    Average. S&P Dow Jones Indices are not responsible for and have not participated in the design, development, pricing, and operation of the products, including the calculation of any interest payments or any other values credited to the products.
    S&P Dow Jones Indices have no obligation or liability in connection

  with the administration, marketing, or trading of products. There is no assurance that
    investment products based on the Index and Average will accurately track index performance or provide positive investment returns. S&P Dow Jones Indices LLC and its subsidiaries are not investment advisors. Inclusion of a security or futures
    contract within an index is not a recommendation by S&P Dow Jones Indices to buy, sell, or hold such security or futures contract, nor is it considered to be investment advice. Notwithstanding the foregoing, CME Group Inc. and its affiliates may
    independently issue and/or sponsor financial products unrelated to products currently being issued by Allianz, but which may be similar to and competitive with Allianz products. In addition, CME Group Inc., an indirect minority owner of S&P Dow
    Jones Indices LLC, and its affiliates may trade financial products which are linked to the performance of the Index and Average. It is possible that this trading activity will affect the value of the products.

  S&P DOW JONES INDICES DO NOT GUARANTEE THE ADEQUACY, ACCURACY, TIMELINESS, AND/OR
    THE COMPLETENESS OF THE INDEX AND AVERAGE OR ANY DATA RELATED THERETO OR ANY COMMUNICATION, INCLUDING BUT NOT LIMITED TO, ORAL OR WRITTEN COMMUNICATION (INCLUDING ELECTRONIC COMMUNICATIONS) WITH RESPECT THERETO. S&P DOW JONES INDICES SHALL NOT BE
    SUBJECT TO ANY DAMAGES OR LIABILITY FOR ANY ERRORS, OMISSIONS, OR DELAYS THEREIN. S&P DOW JONES INDICES MAKE NO EXPRESS OR IMPLIED WARRANTIES, AND EXPRESSLY DISCLAIM ALL WARRANTIES, OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OR USE OR
    AS TO RESULTS TO BE OBTAINED BY ALLIANZ, OWNERS OF THE PRODUCTS, OR ANY OTHER PERSON OR ENTITY FROM THE USE OF THE INDEX AND AVERAGE OR WITH RESPECT TO ANY DATA RELATED THERETO. WITHOUT LIMITING ANY OF THE FOREGOING, IN NO EVENT WHATSOEVER SHALL
    S&P DOW JONES INDICES BE LIABLE FOR ANY INDIRECT, SPECIAL, INCIDENTAL, PUNITIVE, OR CONSEQUENTIAL DAMAGES INCLUDING BUT NOT LIMITED TO, LOSS OF PROFITS, TRADING LOSSES, LOST TIME, OR GOODWILL, EVEN IF THEY HAVE BEEN ADVISED OF THE POSSIBILITY OF
    SUCH DAMAGES, WHETHER IN CONTRACT, TORT, STRICT LIABILITY, OR OTHERWISE. THERE ARE NO THIRD- PARTY BENEFICIARIES OF ANY AGREEMENTS OR ARRANGEMENTS BETWEEN S&P DOW JONES INDICES AND ALLIANZ OTHER THAN THE LICENSORS OF S&P DOW JONES INDICES.]

  [The NASDAQ-100 Index® includes 100 of the largest domestic and international non-financial
    securities listed on The NASDAQ Stock

  Market® based on market capitalization.

  The Product(s) is not sponsored, endorsed, sold or promoted by Nasdaq, Inc. or its
    affiliates (Nasdaq, with its affiliates, are referred to as the “Corporations”). The Corporations have not passed on the legality or suitability of, or the accuracy or adequacy of descriptions and disclosures relating to, the Product(s). The
    Corporations make no representation or warranty, express or implied to the owners of the

  Product(s) or any member of the public regarding the advisability of investing in
    securities generally or in the Product(s) particularly, or the ability of the Nasdaq-100 Index® to track general stock market performance. The Corporations’ only relationship to Allianz Life Insurance Company of North America (“Licensee”) is
    in the licensing of the NASDAQ®, and Nasdaq-100 Index® registered trademarks, and certain trade names of the Corporations and the use of the Nasdaq-100 Index® which is determined, composed and calculated by NASDAQ
    without regard to Licensee or the Product(s). Nasdaq has no obligation to take the needs of the Licensee or the owners of the Product(s) into consideration in determining, composing or calculating the Nasdaq-100 Index®. The Corporations are
    not responsible for and have not participated in the determination of the timing of, prices of, or quantities of the Product(s) to be issued or in the determination or calculation of the equation by which the Product(s) is to be converted into cash.
    The Corporations have no liability in connection with the administration, marketing or trading of the Product(s).

  THE CORPORATIONS DO NOT GUARANTEE THE ACCURACY AND/OR UNINTERRUPTED CALCULATION OF THE
    NASDAQ-100 INDEX® OR ANY DATA INCLUDED THEREIN. THE CORPORATIONS MAKE NO WARRANTY, EXPRESS OR IMPLIED, AS TO RESULTS TO BE OBTAINED BY LICENSEE, OWNERS OF THE PRODUCT(S), OR ANY OTHER PERSON OR ENTITY FROM THE USE OF THE NASDAQ-100 INDEX®
    OR ANY DATA INCLUDED THEREIN. THE CORPORATIONS MAKE NO EXPRESS OR IMPLIED WARRANTIES, AND EXPRESSLY DISCLAIM ALL WARRANTIES

  OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OR USE WITH RESPECT TO THE
    NASDAQ-100 INDEX® OR ANY DATA INCLUDED THEREIN. WITHOUT LIMITING ANY OF THE FOREGOING, IN NO EVENT SHALL THE CORPORATIONS HAVE ANY LIABILITY FOR ANY LOST PROFITS OR SPECIAL, INCIDENTAL, PUNITIVE, INDIRECT, OR CONSEQUENTIAL DAMAGES, EVEN IF
    NOTIFIED OF THE POSSIBILITY OF SUCH DAMAGES.]

  
    
      	
              IXA-APP-04

            

      	
              Page [10 of ]

            

      	
              [(5/2023)]

            

      

      

    

    
      

    

  

  

  

  [The Russell 2000® Index is an equity index that measures the
    performance of the 2,000 smallest companies in the Russell 3000® Index, which is made up of 3,000 of the biggest U.S. stocks. The Russell 2000® Index is constructed to provide a comprehensive and unbiased small-cap barometer and
    is completely reconstituted annually to ensure larger stocks do not affect the performance and characteristics of the true small-cap index.

  The Russell 2000® Index (the “Index”) is a trademark of Frank Russell
    Company (“Russell”) and has been licensed for use by Allianz Life Insurance Company of North America (“Allianz”). Allianz products are not in any way sponsored, endorsed, sold or promoted by Russell or the London Stock Exchange Group companies (“LSEG”)
    (together the “Licensor Parties”) and none of the Licensor Parties make any claim, prediction, warranty or representation whatsoever, expressly or impliedly, either as to (i) the results to be obtained from the use of the Index (upon which the Allianz
    product is based), (ii) the figure at which the Index is said to stand at any particular time on any particular day or otherwise, or (iii) the suitability of the Index for the purpose to which it is being put in connection with the Allianz product.
    None of the Licensor Parties have provided or will provide any financial or investment advice or recommendation in relation to the Index to Allianz or to its clients. The Index is calculated by Russell or its agent. None of the Licensor Parties shall
    be (a) liable (whether in negligence or otherwise) to any person for any error in the Index or (b) under any obligation to advise any person of any error therein.]

  [The EURO STOXX 50®, Europe’s leading blue-chip index for the Eurozone,
    provides a blue-chip representation of supersector leaders in the Eurozone. The index covers 50 stocks from 11 Eurozone countries: Austria, Belgium, Finland, France, Germany, Ireland, Italy, Luxembourg, the Netherlands, Portugal and Spain.

  STOXX Limited, Deutsche Börse Group and their licensors, research partners or data providers have no
    relationship to Allianz Life Insurance Company of North America (“Allianz”), other than the licensing of the EURO STOXX 50® and the related trademarks for use in connection with Allianz products.

  STOXX, Deutsche Börse Group and their licensors, research partners or data providers do
    not:

  
    	
            •

          	
            sponsor, endorse, sell or promote Allianz products.

          

  

  
    	
            •

          	
            recommend that any person invest in Allianz products or any other securities.

          

  

  
    	
            •

          	
            have any responsibility or liability for or make any decisions about the timing, amount or pricing of Allianz products.

          

  

  
    	
            •

          	
            have any responsibility or liability for the administration, management or marketing of Allianz products.

          

  

  
    	
            •

          	
            consider the needs of Allianz products or the owners of Allianz products in determining,
              composing or calculating the EURO STOXX 50 or have any obligation to do so.

          

  

  STOXX, Deutsche Börse Group and their licensors, research
    partners or data providers give no warranty, and exclude any liability (whether in negligence or otherwise), in connection with the Allianz products or their performance.

  STOXX does not assume any contractual relationship with the purchasers of Allianz products or any other
    third parties.

  Specifically,

  
    	
            •

          	
            STOXX, Deutsche Börse Group and their licensors, research partners or data providers do not give
              any warranty, express or implied, and exclude any liability about:

          

  

  
    	
            •

          	
            The results to be obtained by Allianz products, the owner of Allianz products or any other person in connection with the use of the EURO

          

  

  STOXX 50 and the data included in the EURO STOXX 50;

  
    	
            •

          	
            The accuracy, timeliness, and completeness of the EURO STOXX 50 and its data;

          

  

  
    	
            •

          	
            The merchantability and the fitness for a particular purpose or use of the EURO STOXX 50 and its data;

          

  

  
    	
            •

          	
            The performance of Allianz products generally.

          

  

  
    	
            •

          	
            STOXX, Deutsche Börse Group and their licensors, research partners or data providers give no warranty and exclude any liability, for any

          

  

  errors, omissions or interruptions in the EURO STOXX 50 or its data;

  
    	
            •

          	
            Under no circumstances will STOXX, Deutsche Börse Group or their licensors, research partners
              or data providers be liable (whether in negligence or otherwise) for any lost profits or indirect, punitive, special or consequential damages or losses, arising as a result of such errors, omissions or interruptions in the EURO STOXX 50 or
              its data or generally in relation to Allianz products, even in circumstances where STOXX, Deutsche Börse Group or their licensors, research partners or data providers are aware that such loss or damage may occur.

          

  

  The licensing Agreement between Allianz and STOXX is solely for their benefit and not for the benefit of
    the owners of Allianz products or

  any other third parties.]

  [The iShares® MSCI Emerging Markets ETF distributed by BlackRock
    Investments, LLC. iShares®, BLACKROCK®, and the corresponding logos are registered trademarks of BlackRock, Inc. and its affiliates (“BlackRock”) and are used under license. These trademarks have been licensed for certain purposes
    by Allianz Life Insurance Company of North America (“Allianz”) and its wholly-owned subsidiaries. Products offered by Allianz or its wholly-owned subsidiaries are not sponsored, endorsed, sold or promoted by BlackRock, and purchasers of such

  products do not acquire any interest in the iShares® MSCI Emerging
    Markets ETF nor enter into any relationship of any kind with BlackRock. BlackRock makes no representations or warranties, express or implied, to the owners of any products offered by Allianz or its wholly-owned subsidiaries, or any member of the public
    regarding the advisability of purchasing a product from Allianz or its wholly-owned subsidiaries.

  BlackRock has no obligation or liability for any errors, omissions, interruptions
    or use of the iShares MSCI Emerging Markets ETF or any data related thereto, or with the operation, marketing, trading or sale of any products or services offered by Allianz and its wholly-owned subsidiaries. ]

  

  

  
    	
            IXA-APP-04

          

    	
            Page [11 of ]

          

    	
            [(5/2023)]Traditional Death Benefit Rider

  

  

  

  

  This rider forms a part of the Base Contract to which it is attached and is effective on the Issue Date
    shown on the Contract Schedule. Defined terms and contractual provisions are set forth in the Base Contract or are added in this rider. This rider terminates as indicated under the Termination of this Rider provision. This is a first-to-die rider.

  

  

  Definitions

  

  

  

  

  Base Contract

  The contract to which this rider is attached.

  

  

  Determining Life (Lives)

  The person(s) on whose life (lives) we base the Traditional Death Benefit. We establish the Determining Life (Lives) on the Issue Date.

  

  

  On the Issue Date:

  
    	
            •

          	
            If the Base Contract is solely owned, the Determining Life is the Owner.

          

  

  
    	
            •

          	
            If the Base Contract is owned by a non-individual, the Determining Life is the Annuitant.

          

  

  
    	
            •

          	
            If the Base Contract is jointly owned and the Joint Owners are Spouses, the Determining Lives are the Joint Owners.

          

  

  

  

  After the Issue Date, if a Determining Life (Lives) is no longer a Spouse of the Owner or Joint Owner, we will remove that
    person from this rider. If you add or change a Joint Owner, that person will become a Determining Life if they are the current Spouse of an existing Owner.

  

  

  For jointly owned non-qualified contracts, if you establish a trust and change ownership to the trust, the prior Joint
    Owner who is not the Annuitant no longer qualifies as a Determining Life and we remove him or her as such from this rider.

  

  

  Death Benefit

  

  

  

  

  The following is replacing the “Death Benefit” provision of the Base Contract. If this rider terminates,
    the original “Death Benefit” provision of the Base Contract applies.

  

  

  Traditional Death Benefit

  During the Accumulation Phase, if you (the Owner, or Annuitant if the Owner is a non-individual) are a
    Determining Life and you die, or if you die within 120 hours of a Determining Life (Lives), the Traditional Death Benefit is equal to the greater of (a) or (b).

  
    	
            (a)

          	
            The Contract Value minus any final Contract Charges except the Contract Maintenance Charge.

          

  

  
    	
            (b)

          	
            The total of all Purchase Payments received reduced proportionately by the percentage of Contract Value withdrawn as a Partial
              Withdrawal, including any Withdrawal Charge.

          

  

  
    	
            •

          	
            For a sole Beneficiary, we determine (a) and (b) at the end of the Business Day we receive a Valid Claim from the Beneficiary.

          

  

  
    	
            •

          	
            For multiple Beneficiaries, we determine (b) for each surviving Beneficiary’s portion of the Traditional Death Benefit at the end of the
              Business Day we receive the first Valid Claim from any one Beneficiary. We determine (a) for each surviving Beneficiary’s portion of the Traditional Death Benefit as of the end of the Business Day we receive the Beneficiary’s Valid Claim.

          

  

  

  

  However, if you (the Owner, or Annuitant if the Owner is a non-individual) and the Determining Life (Lives) are different individuals:

  
    	
            •

          	
            If any Determining Life dies before you, we compare (a) and (b) determined at the end of Business Day we receive due proof of a
              Determining Life’s death. If (a) is less than (b), we increase (a) to equal (b). The difference between the (b) and (a) will be placed in the Interim Fund(s). On the next Index Anniversary, we then allocate the Variable Account Value in the
              Interim Fund(s) among your selected Index Options according to your allocation instructions.

          

  

  
    	
            •

          	
            If you die before any Determining Life, the Traditional Death Benefit is unavailable and instead your Beneficiary(s) will receive the Death Benefit
              described in the Base Contract.

          

  

  

  

  Any part of the Death Benefit that is in the subaccounts remains there until distributed.

  
    
      	
              S40880-01

            

      	 

      	
              [Admin. Tracking Identifier]

            

      

      

    

    
      

    

  

  

  

  Death Benefit continued from previous page

  

  

  

  

  The following is added to the “Continuation of Contract by the Surviving Spouse” provision of the Base Contract.

  

  

  If at the end of the Business Day that the contract continues, (b) is greater than (a), then the difference between the (b) and (a) will be placed
    in the Interim Fund(s). On the next Index Anniversary, we then allocate the Variable Account Value in the Interim Fund(s) among the selected Index Options according to your allocation instructions.

  

  

  Ownership

  

  

  

  

  The following is added to the “Assignment of this Contract” and “Change of Ownership” provisions of the Base Contract.

  

  

  Assignment of this Contract

  An assignment does not change any Determining Life, except as described under the definition of “Determining Life (Lives)”.

  

  

  Change of Ownership

  A change of ownership does not change any Determining Life, except as described under the definition of “Determining Life (Lives)”.

  

  

  Rider Fee

  

  

  

  

  

  

  There is no fee for this rider.

  

  

  Termination of this Rider

  

  

  

  

  This rider terminates on the earliest of the following.

  
    	
            •

          	
            The Business Day that (a) and (b) are both zero.

          

  

  
    	
            •

          	
            The Business Day before the Annuity Date.

          

  

  
    	
            •

          	
            Upon the death of a Determining Life, the end of the Business Day we receive a Valid Claim from all Beneficiaries, if the Determining
              Life is the Owner (or Annuitant if the Owner is a non-individual) or if the Determining Life dies simultaneously with the Owner.

          

  

  
    	
            •

          	
            Upon the death of a Determining Life, the end of the Business Day we receive an Authorized Request of due proof of the Determining Life’s death, if the
              Determining Life is no longer an Owner (or Annuitant if the Owner is a non-individual).

          

  

  
    	
            •

          	
            Upon the death of an Owner (or Annuitant if the Owner is a non-individual), the end of the Business Day we receive the first Valid Claim from any one
              Beneficiary, if the Owner is no longer a Determining Life.

          

  

  
    	
            •

          	
            The Business Day that the Base Contract terminates.

          

  

  
    
      	
              S40880-01

            

      	 

      	
              [Admin. Tracking Identifier]

            

      

      

    

    
      

    

  

  

  

  In all other respects the provisions, conditions, exceptions and limitations contained in the Base
    Contract remain unchanged. Signed for the Company at its home office.

  Allianz Life Insurance Company

  Of North America

  

  

  By: /s/ GRETCHEN CEPEK

  [Gretchen Cepek]

  Secretary

  

  

  By: /s/ JASMINE M. JIRELE

  [Jasmine M. Jirele]

  President and CEO

  

  

  

  

  To obtain information, make an inquiry, or for assistance with a complaint, please call our
    toll-free number at [800.624.0197].

  
    	
            S40880-01

          

    	 

    	
            [Admin. Tracking Identifier]

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