Document:

a4c.htm

	
Allianz Life Insurance Company

	
of North America

	
Allianz [Index AdvantageSM] Variable Annuity Application

	  	  	  	  	
[Contract number: ___________________]

	
1.

	
Annuity registration

	
Ownership is

	
[■  Individual/Joint

	
■  Qualified plan

	
■  Custodian

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

	  	
■  UTMA/UGMA

	
■  Other]

	
Owner

	  
	
Individual Owner first name

 

	
MI

 

	
Last name

 

	
Jr., Sr., III

 

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

	  
	
Social Security Number or Tax ID Number

 

	
Mailing address

 

	
Email address

 

	
City

 

	
State

 

	
ZIP code

 

	  	
Home telephone number

 

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

 

	
City

 

	
State

 

	
ZIP code

 

	  	
Cell phone number

 

	
Gender

	
■  Male

	
Date of birth (mm/dd/yyyy)

	
Are you a non-resident alien?

	  	
■  Female

	  	
■  Yes  (Attach W8 BEN)   ■  No

	
Joint Owner

	
First name

 

	
MI

 

	
Last name

 

	
Jr., Sr., III

 

	
Mailing address

 

	
Email address

 

	
City

 

	
State

 

	
ZIP code

 

	
Home telephone number

 

	
Gender

	
Date of birth (mm/dd/yyyy)

	
Are you a non-resident alien?

	
■  Male

	
■  Female

	  	
■  Yes  (Attach W8 BEN)   ■  No

	
Relationship to Owner

 

	
Social Security Number

 

	
Annuitant (Complete if different from Owner.)

	  	  	  
	
First name

 

	
MI

 

	
Last name

 

	
Jr., Sr., III

 

	
Mailing address

 

	
Email address

	
City

 

	
State

	
ZIP code

	
Home telephone number

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

 

	
City

 

	
State

	
ZIP code

	
Cell phone number

	
Gender

	
Social Security Number

	
Date of birth (mm/dd/yyyy)

	
Are you a non-resident alien?

	
■  Male

	
■  Female

	  	  	
■  Yes  (Attach W8 BEN)   ■  No

	
F40538

	
Page 1 of [6]

	
[(7/2013)]

  

  

  

	
2.

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

 

Include replacement forms if required

Method of Payment (Select all that apply)

 

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

	
Plan type at prior financial institution or contribution instructions:

	
Qualified

	
Roth (Qualified)

	
■ Traditional IRA

	
■ Contribution to Roth IRA for year ______________

	
■ SEP IRA

	
■ Roth IRA

	
■ Employer Contribution to SEP IRA

	
Nonqualified

	
■ Contribution to Traditional IRA for year_______

	
■ Other nonqualified payment

	
■ Qualified Plan (401(a) plan)

	  
	
■ Other ___________________________

	  

	

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

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

	
Plan type at prior financial institution or contribution instructions:

	
Qualified

	
Nonqualified

	
■ Traditional IRA

	
■ Contribution to Roth IRA for year ______________

	
■ SEP IRA

	
■ Roth IRA

	
■ Employer Contribution to SEP IRA

	
Nonqualified

	
■ Contribution to Traditional IRA for year_______

	
■ 1035 Exchange

	
■ Qualified Plan (401(a) plan)

	
■ Other nonqualified payment

	
■ Other ___________________________

	  

	
3.

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

These are the only available options.

	  	
Nonqualified:

	
■Nonqualified

	  	  	  	  
	  	
IRA:

	
■Traditional IRA

	
■

	
SEP IRA

	
■

	
Roth IRA

	
■

	
Roth IRA (conversion )

	  
	  	
Qualified plans:

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

	  

	
4.

	
Allocation Option transfer and allocation authorization

	
■ Yes

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

	  

	
5.

	
Replacement (This section must be completed.)

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

	
■  Yes

	
■  No

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

	
■  Yes

	
■  No

	  

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

	
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Page 2 of [6]

	
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[6.

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

 

	
  

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

	
  

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

	
  

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

	
  

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

	  	  	  
	  	
■ Earliest Index Effective Date OR ■ Deferred Index Effective Date

	  
	  	  	  

	
  

	
[7.Allocation Options]

 

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

	
  

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

	
  

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

	
  

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

	  	
Variable Options

Asset Allocation                                                                                                              Cash Equivalent

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

	  
	  	
____% AZL® MVP Growth Index Strategy Fund

	  
	  	  	  
	  	
Index Options

	  
	  	
Performance Strategy                                                                                                  Protection Strategy

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

	  
	  	
____% Russell 2000® Index Performance Strategy

	  
	  	
____% S&P 500® Index Performance Strategy

	  
	  	  	  
	  	
Total of _______ % (must equal 100%)

 

	  

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

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

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

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

	
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Page 3 of [6]

	
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[8.]

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

	  	
■  Primary

	  	
Percentage

	
Relationship

	  	
Social Security Number or Tax ID Number

	
Phone Number

	  
	  	
■  Contingent

	  	  	  	  	  	  	  	  	  
	  	
First name

	
MI    Last Name

	  	
Date of birth (mm/dd/yy0

	
Gender

	  
	  	  	  	  	  	
■ Male    ■ Female

	  
	  	
Street Address

	  	
City   State

	
Zip Code

	  
	  	  	  	  	  	  
	  	
■  Primary

	  	
Percentage

	
Relationship

	  	
Social Security Number or Tax ID Number

	
Phone Number

	  
	  	
■  Contingent

	  	  	  	  	  	  	  	  	  
	  	
First name

	
MI    Last Name

	  	
Date of birth (mm/dd/yy0

	
Gender

	  
	  	  	  	  	  	
■ Male    ■ Female

	  
	  	
Street Address

	  	
City   State

	
Zip Code

	  
	  	  	  	  	  	  
	  	
■  Primary

	  	
Percentage

	
Relationship

	  	
Social Security Number or Tax ID Number

	
Phone Number

	  
	  	
■  Contingent

	  	  	  	  	  	  	  	  	  
	  	
First name

	
MI    Last Name

	  	
Date of birth (mm/dd/yy0

	
Gender

	  
	  	  	  	  	  	
■ Male    ■ Female

	  
	  	
Street Address

	  	
City   State

	
Zip Code

	  
	  	  	  	  	  	  

	  	
Non-individual Beneficiary information

	  
	  	
■ Qualified plan

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

	
■ Charitable Trust

	
■ Other

	  
	  	
Name of plan, custodian, trust, etc:

	  	  
	  	
■  Primary

	  	
Percentage

	
Social Security Number or Tax ID Number           Phone Number

	  
	  	
■  Contingent

	  	  	  	  	  	  	  

	
[9].

	
Financial Professional

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

	
  

	
•

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

	
  

	
•

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

	
  

	
•

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

	
  

	
•

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

	
  

	
•

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

	  	  	  	  	  
	
Financial Professional’s signature (primary contact)

	
B/D Rep. ID

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

	  	
Percent split

	  
	  	  	  	  	  
	
Financial Professional’s signature (split case)

	
B/D Rep. ID

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

	  	
Percent split

	  
	  	  	  	  	  
	
Financial Professional’s signature (split case)

	
B/D Rep. ID

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

	  	
Percent split

	  
	  	  	  	  	  
	  	  	  	  	  
	
Financial Professional’s address

	
Registered Representative’s telephone number

	  
	  	  	  	  
	
Financial Professional’s preferred method of contact

	
■ Phone number

	
■ Email address

	  	  
	
Broker/dealer name (please print)

	
Authorized signature broker/dealer (if required)

	  	  
	  	  	  	  
	
Commission options

■ A    ■ B

	  	  	  

	
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Page 4 of [6]

	
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[10].

	
Statement of Owner

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

 

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

Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fi nes, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person fi les an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

New Mexico: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR A STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. THIS ACTIVITY SUBJECTS SUCH A PERSON TO CRIMINAL AND CIVIL PENALTIES.

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

Oklahoma: WARNING: Any person who knowingly, and with

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

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

 

 

 

 

	
F40538

	
Page 5 of [6]

	
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[10].

	
Statement of Owner (Continued)

 

 

 

By signing below, the Owner acknowledges the applicable statements mentioned above and agrees to the following:

 

	
•

	
I received a prospectus and have determined that the variable annuity applied for is not unsuitable for my investment objectives, financial situation, and financial needs. It is a long-term commitment to meet my financial needs and goals.

 

	
•

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

	
•

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

 

	
•

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

 

 

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

 

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

 

 

	
_______________________________________________

	
______________________________________________________

	
Owner signature

	
Joint Owner signature

	  	  
	  	  
	
Signed at (City, State)

	
Signed date

	
 

Trust:_________________________________

	
as trustee of the :______________________________

	
____________________

	
Trustee’s signature

	
Trust name (printed)

	
Signed date

	  	  	  
	
Power-of Attorney:_______________________

	
by :_________________________________________

	
____________________

	
Contract owner’s name

	
Attorney-in-fact signature

	
Signed date

	  	  	  

	
  

	
Mailing information

Please call Allianz with any questions at [800.624.0197].

	  	  	
Mailing information

	  	  	  
	  	  	  	  	  
	  	  	
Applications that HAVE a check attached

	  	  	  
	  	
Regular mail

	
Overnight, certified, or registered

	  	  	  
	  	
Allianz Life Insurance Company of North America

	
Allianz Life Insurance Company of North America

	  	  	  
	  	
NW 5989

	
NW 5989 Allianz

	  	  	  
	  	
PO Box 1450

	
1350 Energy Lane, Ste. 200

	  	  	  
	  	
Minneapolis, MN 55485-5989

	
St. Paul, MN 55108-5254

	  	  	  
	  	  	
Applications that DO NOT HAVE a check attached

	  	  	  
	  	
Regular mail

	
Overnight, certified, or registered

	  	  	  
	  	
Allianz Life Insurance Company of North America

	
Allianz Life Insurance Company of North America

	  	  	  
	  	
PO Box 561

	
5701 Golden Hills Drive

	  	  	  
	  	
Minneapolis, MN 55440-0561

	
Golden Valley, MN 55416-1297

	  	  	  

	
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Page 6 of [6]

	
[(7/2013)]a4d.htm

	
Index Performance Strategy Rider

This rider forms a part of the Base Contract to which it is attached and is effective on the Index Effective Date shown on your Index Options statement.  In the case of a conflict with any provision in the Base Contract, the provisions of this rider control. 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.

	
Definitions

Base Contract

The contract to which this rider is attached.

Buffer

A Buffer is the maximum negative Index Return that we will absorb.  On the Index Effective Date, we declare a Buffer for each Index Option, and the Buffers will not change.  The Buffers are shown on the Index Options Contract Schedule.

Cap

A Cap is the maximum positive Performance Credit for an Index Option on an Index Anniversary.  On the Index Effective Date, and on subsequent Index Anniversaries, we declare a Cap for each Index Option and guarantee them for the Index Year.  Caps are shown on your Index Options statement each year and will never be less than the Minimum Cap shown on the Index Options Contract Schedule.

Index Option Base

The value used to determine the dollar amount of the Performance Credit.  We establish an Index Option Base for each Index Option.

Index Option Value

The value in a selected Index Option.  We establish an Index Option Value for each Index Option.

Index Value

The value of an Index at the end of the Business Day.  Index Values are shown on your Index Options statement.

Performance Credit

The annual return you may receive when you allocate money to an Index Performance Strategy Index Option(s).

	
Contract Value

The following is added to the “Contract Value” section.

How we calculate Index Option Values

On the Index Effective Date, the Index Option Value and Index Option Base for each Index Option are equal to:

	
·  

	
The portion of the Initial Purchase Payment allocated to that Index Option, if the Index Effective Date is the Issue Date; or

	
·  

	
The portion of Variable Account Value allocated to that Index Option, if the Index Effective Date is not the Issue Date.

At the end of each Business Day other than the Index Effective Date or Index Anniversary, the Index Option Value is equal to the Index Option Base plus its Daily Adjustment.  We establish a Proxy Value to calculate the Daily Adjustment.  The Proxy Value is determined on each Business Day based on the value of a hypothetical set of put and call options as determined by an option pricing formula.  The Daily Adjustment is calculated before we process any Partial Withdrawal or deduct any Contract Charges using the Index Option Base, the current Proxy Value, and the Proxy Value as of the previous Index Anniversary (or the Index Effective Date if this is the first Index Year).

At the end of each Business Day, we reduce each Index Option Value by the dollar amount withdrawn from the Index Option, including any Withdrawal Charge, and Contract Charges.  We deduct money from an Index Option proportionately based on the percentage of Contract Value in each Allocation Option, unless you specify otherwise.  We then reduce each Index Option Base by the same percentage that the amount withdrawn reduced its associated Index Option Value.

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Contract Value continued from the previous page

On each Index Anniversary, we calculate the Index Option Value for each Index Performance Strategy Index Option by applying its associated Performance Credit to its Index Option Base.  If the Index Anniversary is not a Business Day, we calculate the Performance Credit on the next Business Day.

On the Index Anniversary, we determine the Index Return for each Index Option.  The Index Return is  the Index Value for the current Index Anniversary, minus  the Index Value from the previous Index Anniversary (or the Index Effective Date if this is the first Index Anniversary), divided by the Index Value from the previous Index Anniversary (or the Index Effective Date if this is the first Index Anniversary).

If the Index Return is positive and greater than the Cap for an Index Option, then the Performance Credit for that Index Option is equal to the Cap.  If the Index Return is positive, but less than the Cap, then the Performance Credit for that Index Option is equal to the Index Return.  If the Index Return is zero or negative, but within the Buffer, then the Performance Credit for that Index Option is zero.  If the Index Return is negative and extends beyond the Buffer, then the Performance Credit for that Index Option is equal to the Index Return plus the Buffer.

For each Index Option that receives a Performance Credit, we multiply its Performance Credit by its Index Option Base.  This result is then added to its Index Option Base.  We then set each Index Option Value equal to its Index Option Base.

Then, on each Index Anniversary, for each Index Option we:

	
·  

	
Increase its Index Option Value and Index Option Base by the amount of any Additional Purchase Payments and Transfers into the Index Option received that day;

	
·  

	
Reduce its Index Option Value and Index Option Base by the amount transferred out of the Index Option; and

	
·  

	
Reduce its Index Option Value and Index Option Base for Withdrawals (including any Withdrawal Charge) and Contract Charges as described above.

At the end of each Business Day we apply the Alternate Minimum Value if we pay a Death Benefit, upon annuitization, if you take a Withdrawal, or if you Transfer Contract Value from an Index Option to a Variable Option.

	
Alternate Minimum Value

The Alternate Minimum Value provides a guaranteed minimum value on each of your Index Option Values when we pay a Death Benefit, upon annuitization, if you take a Withdrawal, or if you Transfer Contract Value from an Index Option to a Variable Option.

When we pay a Death Benefit, upon annuitization, or if you take a Full Withdrawal, we compare each of your Index Option Values (after deducting any applicable fees or charges) with its Alternate Minimum Value.  If your Index Option Value is less than its Alternate Minimum Value, we add the difference to the Index Option Value before determining the amount of the Death Benefit, Annuity Payment, or Withdrawal.

If you take a Partial Withdrawal or if you Transfer Index Option Value from an Index Option to a Variable Option, we compare the percentage of Index Option Value withdrawn (including any Withdrawal Charge) with an equivalent percentage of its Alternate Minimum Value.  If the percentage of Index Option Value is less than the equivalent percentage of Alternate Minimum Value, we add the difference to the amount we pay to you as a Partial Withdrawal or to the amount transferred.

On the Index Effective Date, each Alternate Minimum Value is equal to its associated Index Option Base multiplied by the AMV Factor shown on the Index Options Contract Schedule.  We establish an Alternate Minimum Base to calculate interest.  On the Index Effective Date, we set each Alternate Minimum Base equal to the AMB Factor multiplied by its Index Option Base.  The AMB Factor is shown on your Index Options Contract Schedule.  On each Business Day, each Alternate Minimum Value is equal to the AMV Factor multiplied by its Index Option Base on the last Index Anniversary (or the Index Effective Date if this is the first Index Year) (adjusted proportionately for any Withdrawals, including any Withdrawal Charge) plus the Accumulated Alternate Interest and any Daily Adjustment.  The Accumulated Alternate Interest is the total amount of Alternate Interest accrued since the Index Effective Date.

We credit Alternate Interest to each Alternate Minimum Value at the end of the day.  Each daily Alternate Interest is equal to the Alternate Interest Rate divided by 365 and then multiplied by its Alternate Minimum Base.  On the Issue Date, we declare the Alternate Interest Rate and guarantee it for the life of the contract.  The Alternate Interest Rate is shown on your Index Options Contract Schedule.

S40878                                                                                2

  

  

  

	
Alternate Minimum Value continued from the previous page

If you take a Partial Withdrawal, or if you Transfer Index Option Value from an Index Option to a Variable Option, each Alternate Minimum Value, Alternate Minimum Base, and Accumulated Alternate Interest is reduced by the percentage of the Index Option Value withdrawn or transferred, including any Withdrawal Charge.

If you Transfer Index Option Value from an Index Option to another Index Option, we also Transfer Accumulated Alternate Interest.  The dollar amount of Accumulated Alternate Interest transferred is equal to the dollar amount of Index Option Value transferred divided by the total Index Option Value for the Index Option prior to the Transfer, then multiplied by the Accumulated Alternate Interest for the Index Option prior to the Transfer.

On each Index Anniversary, we reset each Alternate Minimum Base to equal its Index Option Base multiplied by the AMB Factor plus its Accumulated Alternate Interest.

	
Performance Lock

You can request a Performance Lock of the current Index Option Value for each of your unlocked Index Options by providing an Authorized Request.  We process the request on the Business Day we receive an Authorized Request based on the values at the end of the Business Day.  If you exercise a Performance Lock, you may receive less than the full Cap or less than the full protection of the Buffer that you would have received if you waited for us to apply the Performance Credit on the next Index Anniversary.

Once an Index Option Value has been locked:

	
·  

	
The Index Option Value will not change until the next Index Anniversary, unless it is reduced for Withdrawals and any other Contract Charges;

	
·  

	
The locked Index Option will not receive a Performance Credit on the next Index Anniversary; and

	
·  

	
You cannot unlock the Index Option.

On every Index Anniversary, we unlock any previously locked Index Option Values.

	
Termination of this Rider

This rider terminates on the earlier of the Business Day before the Annuity Date or the date the Base Contract terminates.

In all other respects the provisions, conditions, exceptions and limitations contained in the Base Contract remain unchanged and apply to this rider.

Signed for the Company at its home office.

Allianz Life Insurance Company

of North America

[                                                                                                           ]

Gretchen Cepek                                                                Walter R. White

Secretary                                                       President and CEO

S40878                                                                                3

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