Document:

Index Options Contract Schedule

          

    

    

    Owner: [John Doe] Contract Number: [??687456]

    Owner’s Age Issue Date: [04/15/10]

    and gender: [35 Male] Annuitant: [John Doe]

    [Joint Owner: [Jane Doe]] Annuitant’s Age

    [Joint Owner’s and gender: [35 Male]

    Age and gender: [35 Female]]

    

    

    Alternate Minimum Value

    AMV Factor: [87.50]%

    AMB Factor: [87.50]%

    Alternate Interest Rate: [1.00]%

    

    

    Allocation Guidelines:

    [1. Currently, you can select up to [5] of the Index Protection Strategy with Declared Protection Strategy Credit Index
        Options.

    2. Currently, you can select up to [5] of the Index Protection Strategy with Cap Index Options.

    3. Currently, you can select up to [5] of the Index Performance Strategy Index Options.

    4. Currently, you can select up to [5] of the Index Guard Strategy Index Options.

    5. Currently, you can select up to [5] of the Index Precision Strategy Index Options.

    6. Allocations must be made in whole percentages.]

    

    

    Index Options:

    

    

    [Part [A] Index Option Rider(s):]

    [Index Performance Strategy Index Options

    	
            Index

          	
            Buffer for all Index Years

          	
            Minimum Cap for all Index Years

          
	
            [S&P 500® Index

          	
            [10.00]%

          	
            [3.00]%]

          
	
            [Nasdaq-100® Index

          	
            [10.00]%

          	
            [3.00]%]

          
	
            [Russell 2000® Index

          	
            [10.00]%

          	
            [3.00]%]

          
	
            [EURO STOXX 50®

          	
            [10.00]%

          	
            [3.00]%]

          
	
            [iShares® MSCI Emerging
                Markets ETF

          	
            [10.00]%

          	
            [3.00]%]]

          

    [Index Guard Strategy Index Options

    	
            Index

          	
            Floor for all Index Years

          	
            Minimum Cap for all Index Years

          
	
            [S&P 500® Index

          	
            [-10.00]%

          	
            [3.00]%]

          
	
            [Nasdaq-100® Index

          	
            [-10.00]%

          	
            [3.00]%]

          
	
            [Russell 2000® Index

          	
            [-10.00]%

          	
            [3.00]%]

          
	
            [EURO STOXX 50®

          	
            [-10.00]%

          	
            [3.00]%]

          
	
            [iShares® MSCI Emerging
                Markets ETF

          	
            [-10.00]%

          	
            [3.00]%]]

          

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    
      
        S40877-IAI-01                                                                           [Admin Tracking Identifier]

      

      
        

      
        

        

      

    

    

    

    	
            Index Options Contract Schedule continued from the previous page

          

    

    

    [Index Precision Strategy Index Options

    	
            Index

          	
            Buffer for all Index Years

          	
            Minimum Precision Rate for all Index Years

          
	
            [S&P 500® Index

          	
            [10.00]%

          	
            [3.00]%]

          
	
            [Nasdaq-100® Index

          	
            [10.00]%

          	
            [3.00]%]

          
	
            [Russell 2000® Index

          	
            [10.00]%

          	
            [3.00]%]

          
	
            [EURO STOXX 50®

          	
            [10.00]%

          	
            [3.00]%]

          
	
            [iShares® MSCI Emerging
                Markets ETF

          	
            [10.00]%

          	
            [3.00]%]]

          

    

    

    [Part [B] Index Option Rider(s):]

    [Index Protection Strategy with Declared Protection Strategy

     Credit Index Options

    	
            Index

          	
            Minimum Declared Protection Strategy Credit for all Index Years

          
	
            [S&P 500® Index

          	
            [0.50]%]

          
	
            [Nasdaq-100® Index

          	
            [0.50]%]

          
	
            [Russell 2000® Index

          	
            [0.50]%]

          
	
            [EURO STOXX 50®

          	
            [0.50]%]

          
	
            [iShares® MSCI Emerging
                Markets ETF

          	
            [0.50]%]]

          

    

    

    [Index Protection Strategy with Cap Index Options

    	
            Index

          	
            Minimum Cap for all Index Years

          
	
            [S&P 500® Index

          	
            [0.50]%]

          
	
            [Nasdaq-100® Index

          	
            [0.50]%]

          
	
            [Russell 2000® Index

          	
            [0.50]%]

          
	
            [EURO STOXX 50®

          	
            [0.50]%]

          
	
            [iShares® MSCI Emerging
                Markets ETF

          	
            [0.50]%]]

          

    

    

    
      
        S40877-IAI-01                                                                           [Admin Tracking Identifier]

      

      
        

      
        

        

      

    

    

    

    	
            Index Options Contract Schedule continued from the previous page

          

    

    

    [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 at, 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).

    
      
        S40877-IAI-01                                                                           [Admin Tracking Identifier]

      

      
        

      
        

        

      

    

    

    

    	
            Index Options Contract Schedule  continued from the previous page

          

    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.]

    

    

    [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 12 Eurozone countries: Austria, Belgium, Finland, France, Germany, Greece, 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 [relevant index] 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.

    

    

    
      
        S40877-IAI-01                                                                           [Admin Tracking Identifier]

      

      
        

      
        

        

      

    

    

    

    	
            Index Options Contract Schedule  continued from the previous page

          

    

    

    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.]

    

    

    

      
        
          S40877-IAI-01                                                                           [Admin Tracking Identifier]

           

            

           

            

           

            

           

            

          

            

            

            

            

            

            

        

        
          

        
          

          

        

      

      

        

        

        	
                Index Options Contract Schedule Addendum

              

        

        

        Owner: [John Doe] Contract Number: [??687456]

        Owner’s Age Issue Date: [04/15/10]

        and gender: [35 Male] Annuitant: [John Doe]

        [Joint Owner: [Jane Doe]] Annuitant’s Age

        [Joint Owner’s and gender: [35 Male]

        Age and gender: [35 Female]]

        

        

        

        

        The following is replacing the applicable “Allocation Guidelines” section of the Index Options
            Contract Schedule.

        

        

        Allocation Guidelines:

        [1. Currently, you can select up to [5] of the Index Protection Strategy with Declared Protection Strategy Credit Index Options.

        2. Currently, you can select up to [5] of the Index Protection Strategy with Cap Index Options.

        3. Currently, you can select up to [5] of the Index Performance Strategy Index Options.

        4. Currently, you can select up to [5] of the Index Guard Strategy Index Options.

        5. Currently, you can select up to [5] of the Index Precision Strategy Index Options.

        6. Allocations must be made in whole percentages.]

        

        

        The following is added to your Index Options shown on your Index Options Contract Schedule.

        

        

        Index Options:

        

        

        [Part [A] Index Option Rider(s):]

        [Index Performance Strategy Index Options

        	
                Index

              	
                Buffer for all Index Years

              	
                Minimum Cap for all Index Years

              
	
                [iShares® MSCI
                    Emerging Markets ETF

              	
                [10.00]%

              	
                [3.00]%]]

              

        [Index Guard Strategy Index Options

        	
                Index

              	
                Floor for all Index Years

              	
                Minimum Cap for all Index Years

              
	
                [iShares® MSCI
                    Emerging Markets ETF

              	
                [-10.00]%

              	
                [3.00]%]]

              

        

        

        

        

        

        

        

        

        

        

        

        

        

        

        

        

        

        

        [Index Precision Strategy Index Options

        	
                Index

              	
                Buffer for all Index Years

              	
                Minimum Precision Rate for all Index Years

              
	
                [iShares® MSCI
                    Emerging Markets ETF

              	
                [10.00]%

              	
                [3.00]%]]

              

        

        

        
          
            S40877-IAI-ADD                                                                           [Admin Tracking Identifier]

          

          
            

          

        

        

        

        

        

        	
                Index Options Contract Schedule Addendum continued from the previous page

              

        

        

        [Part [B] Index Option Rider(s):]

        [Index Protection Strategy with Declared Protection Strategy

         Credit Index Options

        	
                Index

              	
                Minimum Declared Protection Strategy Credit for all Index Years

              
	
                [iShares® MSCI
                    Emerging Markets ETF

              	
                [0.50]%]]

              

        

        

        [Index Protection Strategy with Cap Index Options

        	
                Index

              	
                Minimum Cap for all Index Years

              
	
                [iShares® MSCI
                    Emerging Markets ETF

              	
                [0.50]%]]

              

        

        

        

        

        [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.]

        

        

        

        

        
          S40877-IAI-ADD                                                                           [Admin Tracking Identifier]Allianz Index Advantage Income Variable Annuity Application[Contract number
          ]  SM                                        Individual Owner first name  MI  Last name  Jr., Sr., III  Mailing address      Email address    City  State  ZIP code    Home telephone number          1. Annuity Registration  Ownership is [
          Individual/Joint Qualified plan Custodian Trust (Include the date of the trust in the name.) UTMA/UGMA Other ]OwnerNon-individual owner name (Attach Non-Individual Ownership Form or Qualified Plan Acknowledgement Form if applicable.)Social
          Security Number/TIN  Street address (required if a PO Box was used for mailing address)  Joint Owner (Must be legally recognized spouses.)  City    State  ZIP code  Cell phone number  GenderMale Female  Date of birth (mm/dd/yyyy)    Are you a
          non-resident alien? Yes No(If yes, then you are not eligible for this product.)    Annuitant (Complete if different from Owner.)  Street address (required if a PO Box was used for mailing address)  Relationship of Annuitant to Owner    Spouse
          under a legally recognized marriage    Other:                   First name  MI  Last name        Jr., Sr., III  Mailing address        Email address      City    State  ZIP code    Home telephone number    GenderMale Female  Date of birth
          (mm/dd/yyyy)    Are you a non-resident alien? Yes No(If yes, then you are not eligible for this product.)        Relationship to OwnerSpouse under a legally recognized marriage Other:         Social Security Number/TIN      Allianz Life Insurance
          Companyof North America  IAI-APP-02  1  [(4/2019)]  First name  MI  Last name        Jr., Sr., III  Mailing address        Email address      City    State  ZIP code    Home telephone number    City      State  ZIP code    Cell phone
          number  GenderMale Female  Social Security Number/TIN  Date of birth (mm/dd/yyyy)      Are you a non-resident alien? Yes No(If yes, then you are not eligible for this product.)   

    

  

   

  
    
      

  

  
    
      

    

    
               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 requiredMethod of Payment (Select all that apply)Purchase Payment enclosed with application. Total amount enclosed: $ Plan type at prior financial institution or
          contribution instructions:                      Qualified Traditional IRA SEP IRAEmployer contribution to SEP IRAContribution to Traditional IRA for year Qualified Plan (401(a) plan)Other   Roth (Qualified)  Contribution to Roth IRA for year
              Roth IRAInherited IRA (Qualified)Inherited IRA Inherited Roth IRANonqualifiedOther nonqualified payment        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 Traditional IRA SEP IRAEmployer contribution to SEP IRAContribution to Traditional IRA for year Qualified Plan (401(a) plan)Other     Roth (Qualified)Contribution to Roth IRA for year
          Roth IRAInherited IRA (Qualified)Inherited IRA Inherited Roth IRANonqualifiedOther nonqualified payment  3. Plan Specifics (This section must be completed to indicate how this Contract should be
          issued.)                                                    IAI-APP-02  2  [(4/2019)]  Nonqualified:  Nonqualified    Qualified plans:  401(a) defined contribution plan  401(a) one person defined benefit plan  IRA:  Traditional IRA SEP IRA  Roth
          IRA Roth IRA (conversion of existing IRA) 

    

  

   

  
    
      

  

  
    
      

    

    
       5. 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
          applicationis 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.  6. Optional Death Benefit    [ Maximum Anniversary Value Death Benefit (Carries an additional charge)]  7. 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 theIndex 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.ORDeferred 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. This option is designed to accommodate multiple Purchase Payments expected before the first Quarterly Contract Anniversary.]  8. Allocation 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.[(continued on next page)]  4. Electronic Authorization      Yes Electronic Authorization – Allianz accepts allocation, transfer, and Performance Lock 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 me as well as my financial professional and/or anyone authorized by
          him/her to transfer and allocate Contract Value among the variable investment options and any other available allocation options and authorization for Performance Locks. I understand I must approve the transactions recommended by my financial
          professional prior to execution, unless I have given my financial professional discretion over my contract. My financial professional shall maintain all required authorizations pursuant to Form ADV, power of attorney, agreement, or otherwise. If
          the box is not checked, electronic instructions will be accepted only from me, the Owner. 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, Performance
          Lock, or allocation instruction change, and to discontinue or modify our electronic instruction privileges at any time for any reason.]  IAI-APP-02  3  [(4/2019)] 

    

  

   

  
    
      

  

  
    
      

    

    
                                                       IAI-APP-02  4  [(4/2019)]  1Required if spouse  Provide a
          year you anticipate starting Income Payments from your Income Benefit. By providing this information you are not required to start Income Payments on this date nor will Allianz automatically begin Income Payments to you.Anticipated Income Benefit
          Year (the year you anticipate starting Income Payments)     8. Allocation Options (continued)  Index OptionsIndex Performance Strategy Index Precision Strategy Index Guard Strategy % EURO STOXX 50® % EURO STOXX 50® % EURO STOXX 50® % Nasdaq-100®
          Index % Nasdaq-100® Index % Nasdaq-100® Index % Russell 2000® Index % Russell 2000® Index % Russell 2000® Index % S&P 500® Index % S&P 500® Index % S&P 500® Index % iShares® MSCI Emerging Markets ETF % iShares® MSCI Emerging Markets
          ETF % iShares® MSCI Emerging Markets ETFIndex Protection Strategy Index Protection Strategy withwith Cap Declared Protection Strategy Credit % EURO STOXX 50® % EURO STOXX 50® % Nasdaq-100® Index % Nasdaq-100® Index % Russell 2000® Index % Russell
          2000® Index % S&P 500® Index % S&P 500® Index % iShares® MSCI Emerging Markets ETF % iShares® MSCI Emerging Markets ETFTotal of % (must equal 100%)  9. Anticipated Income Benefit Date  10. 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        Phone number  Individual first name    MI  Last name    Date of birth
          (mm/dd/yyyy)1      GenderMale Female  Qualified plan Custodian Trust (Include the date of trust in the name.) Charitable TrustNon-individual Beneficiary name              Email    Street address        City    State    ZIP code  Primary
          Contingent  Percentage    Relationship  Social Security Number/TIN        Phone number  Individual first name    MI  Last name    Date of birth (mm/dd/yyyy)1      GenderMale Female  Qualified plan Custodian Trust (Include the date of trust in the
          name.) Charitable TrustNon-individual Beneficiary name              Email    Street address        City    State    ZIP code  Primary Contingent  Percentage    Relationship  Social Security Number/TIN        Phone number  Individual first
          name    MI  Last name    Date of birth (mm/dd/yyyy)1      GenderMale Female  Qualified plan Custodian Trust (Include the date of trust in the name.) Charitable TrustNon-individual Beneficiary name              Email    Street
          address        City    State    ZIP code 

    

  

   

  
    
      

  

  
    
      

    

    
       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)
          withthe 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.            12. 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:The Taxpayer Identification Number shown on this form is correct or I am waiting for a number to be issued to me.I
          am not subject to backup withholding because:I am exempt from backup withholding, orI have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failureto report all interest or dividends,
          orThe IRS has notified me that I am no longer subject to backup withholding.I am a U.S. person, andThe 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 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.]    IAI-APP-02  5  [(4/2019)]    Financial Professional’s signature
          (Primary)          First and last name (please print)              Address            Email            Financial Professional’s signature (Secondary)          First and last name (please
          print)              Email                      Broker/dealer name (please print)            Authorized signature broker/dealer (if required)                        Commission options (please check one)A B C                       

    

  

   

  
    
      

  

  
    
      

    

    
       13. Agreements and Signatures        [The following state requires Owners to read and acknowledge the
          statement for your state below.District of Columbia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and
          may be subject to fines and confinement in prison.]By signing below, I, the Owner, acknowledge the applicable statement(s) mentioned above and 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 withina 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.Please send me a statement of additional information. (Also available at
          [www.allianzlife.com])[The IRS does not require your consent to any provision of this document other than the certifications required to avoidbackup 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/YYYYJoint Owner’s signature: Date: MM/DD/YYYYAlternate signatures, if applicableTrust: as trustee of the: Date: TRUSTEE’S SIGNATURE
          TRUST NAME (PRINTED) MM/DD/YYYYPower of attorney: by: Date: OWNER’S NAME (PRINTED) ATTORNEY IN FACT’S SIGNATURE(S) MM/DD/YYYY    IAI-APP-02  6  [(4/2019)] 

    

  

   

  
    
      

  

  
    
      

    

    
       Please submit your form through one of the options below: Email completed forms
          to:[variableannuity@send.allianzlife.com]ORWeb Upload:You can scan and upload your signed and completed form by logging in to your account at [Allianzlife.com]OR  Mail:[Applications that HAVE a check attached:Regular mailAllianz Life Insurance
          Company of North America NW 5989PO Box 1450Minneapolis, MN 55485-5989]  [Overnight mailAllianz Life Insurance Company of North America NW 59891801 Parkview DriveShoreview, MN 55126]  OR  [Applications that DO NOT HAVE a check attached:Regular
          mailAllianz Life Insurance Company of North America PO Box 561Minneapolis, MN 55440-0561]  [Overnight mailAllianz Life Insurance Company of North America 5701 Golden Hills DriveGolden Valley, MN 55416-1297]  OR[Fax: 763.765.7912][Any questions?
          Call us at 800.624.0197]    IAI-APP-02  7  [(4/2019)] 

    

  

   

  
    
      

  

  
    
      

    

    
       IAI-APP-02  8  [(4/2019)]  [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 theIndex 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 considerationin 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 isnot 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, LOSSOF 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 Corporationsand 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 at, 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. 

    

  

   

  
    
      

  

  
    
      

    

    
       IAI-APP-02  9  [(4/2019)]  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-capbarometer 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 excludeany 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 anyother 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 anymember 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.]

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00294-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00294-of-00352.parquet"}]]