Document:

EX-4.c. Application Ind. Var. Annuity

	
Allianz Life Insurance Company

	
of North America

	
Allianz Index Advantage® 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/TIN

 

	
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? ■  Yes  ■  No

	 	
■  Female

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

	
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? ■  Yes  ■  No

	
■  Male

	
■  Female

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

	
Relationship to Owner

■  Spouse under a legally recognized marriage ■  Other:___________________

	
Social Security Number/TIN

 

	
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/TIN

	
Date of birth (mm/dd/yyyy)

	
Are you a non-resident alien? ■  Yes  ■  No

	
■  Male

	
■  Female

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

	
Relationship of Annuitant to Owner

■  Spouse under a legally recognized marriage ■  Other:___________________

	
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		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

	
Inherited IRA (Qualified)

	
■ Contribution to Traditional IRA for year_______

	
■ Inherited IRA

	
■ Qualified Plan (401(a) plan)

	
■ Inherited Roth IRA

	
■ Other ___________________________

	
Nonqualified

	 	
■ Other nonqualified payment

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

 Total expected amount: $___________________

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

 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_______

	
■ Inherited IRA

	
■ Qualified Plan (401(a) plan)

	
■ Inherited Roth IRA

	
■ Other ___________________________

	
Nonqualified

	 	
■ 1035 Exchange

	 	
■ Other nonqualified payment

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

These are the only available options.

	 	
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 )

	 
	 	
Inherited IRA:

	
■ Inherited IRA   ■ Inherited Roth IRA

	 

		4.	Electronic Transfer and Allocation Instructions

	
■ Yes

	
Electronic Authorization - Allianz accepts allocation and transfer instructions by electronic notification. Electronic authorizations include, but are not limited to, requests received by telephone, fax, or on 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 confirm that these electronic instructions are genuine. 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 or allocation instruction change, and to discontinue or modify our electronic instruction privileges at any time for any reason.

	 

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

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

•  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 – 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.

	 
	 	
OR

	 
	 	
■ Deferred Index Effective Date – If chosen, the deferred Index Effective Date is the first Quarterly Anniversary. You can change the Index Effective Date prior to the first Quarterly Anniversary by contacting Allianz.

	 

		7.	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 and you select an Index Option, the following will occur:

- Your Purchase Payments will be placed in the [AZL® 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 and you select an Index Option, then your Purchase Payment will be placed in the [AZL® 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.

• 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

	 
	 	
Index Performance Strategy

	
Index Protection Strategy

	 
	 	
____% EURO STOXX 50®

	
____% S&P 500® Index

	 
	 	
____% Nasdaq-100® Index

	 	 
	 	
____% Russell 2000® Index

	 	 
	 	
____% S&P 500® Index

	 	 
	 	 	 	 
	 	
Index Guard Strategy

	 	 
	 	
____% EURO STOXX 50®

	 	 
	 	
____% Nasdaq-100® Index

	 	 
	 	
____% Russell 2000® Index

	 	 
	 	
____% S&P 500® Index

	 
	 	
Total of ____% (must equal 100%)

	 

	
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		7.	Allocation Options (continued)

[The EURO STOXX 50® Index, 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 has 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 does 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 will not have any liability in connection with Allianz products. Specifically, STOXX does not make any warranties, express or implied and disclaims any and all warranties 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 or 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; STOXX has no liability for any errors, omissions or interruptions in the EURO STOXX 50® or its data; under no circumstances will STOXX be liable for any lost profits or indirect, punitive, special or consequential damages or losses, even if STOXX knows that they might 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 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 has 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 to track general market performance. S&P Dow Jones Indices' only relationship to Allianz with respect to the Index is the licensing of the Index and certain trademarks, service marks, and/or trade names of S&P Dow Jones Indices and/or its third-party licensors. The Index is 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. 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 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. 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 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 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 THAN THE LICENSORS OF S&P DOW JONES INDICES.]

	
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		7.	Allocation Options (continued)

[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.

Allianz products are not sponsored, endorsed, sold or promoted by The NASDAQ OMX Group, Inc. or its affiliates (NASDAQ OMX, 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, Allianz products.   The Corporations make no representation or warranty, express or implied to the owners of Allianz products or any member of the public regarding the advisability of investing in securities generally or in Allianz products 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®, NASDAQ OMX®, NASDAQ-100®, 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 OMX without regard to Licensee or Allianz products.  NASDAQ OMX has no obligation to take the needs of the Licensee or the owners of Allianz products 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 Allianz products to be issued or in the determination or calculation of the equation by which Allianz products are to be converted into cash. The Corporations have no liability in connection with the administration, marketing or trading of the Allianz products.

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 Allianz products, 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 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.

Allianz products are not sponsored, endorsed, sold or promoted by Frank Russell Company ("Russell"). Russell makes no representation or warranty, express or implied, to the owners of Allianz products or any member of the public regarding the advisability of investing in securities generally or in Allianz products particularly or the ability of the Russell 2000® Index to track general stock market performance or a segment of the same. Russell's publication of the Russell 2000® Index in no way suggests or implies an opinion by Russell as to the advisability of investment in any or all of the securities upon which the Russell 2000® Index is based. Russell's only relationship to Allianz Life Insurance Company of North America ("Allianz") is the licensing of certain trademarks and trade names of Russell and of the Russell 2000® Index which is determined, composed and calculated by Russell without regard to Allianz or Allianz Life of New York products. Russell is not responsible for and has not reviewed the Allianz products nor any associated literature or publications and Russell makes no representation or warranty express or implied as to their accuracy or completeness, or otherwise. Russell reserves the right, at any time and without notice, to alter, amend, terminate or in any way change the Russell 2000® Index. Russell has no obligation or liability in connection with the administration, marketing or trading of Allianz products.

RUSSELL DOES NOT GUARANTEE THE ACCURACY AND/OR THE COMPLETENESS OF THE RUSSELL 2000® INDEX OR ANY DATA INCLUDED THEREIN AND RUSSELL SHALL HAVE NO LIABILITY FOR ANY ERRORS, OMISSIONS, OR INTERRUPTIONS THEREIN. RUSSELL MAKES NO WARRANTY, EXPRESS OR IMPLIED, AS TO RESULTS TO BE OBTAINED BY ALLIANZ, INVESTORS, OWNERS OF ALLIANZ PRODUCTS, OR ANY OTHER PERSON OR ENTITY FROM THE USE OF THE RUSSELL 2000® INDEX OR ANY DATA INCLUDED THEREIN. RUSSELL MAKES NO EXPRESS OR IMPLIED WARRANTIES, AND EXPRESSLY DISCLAIMS ALL WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OR USE WITH RESPECT TO THE RUSSELL 2000® INDEX OR ANY DATA INCLUDED THEREIN. WITHOUT LIMITING ANY OF THE FOREGOING, IN NO EVENT SHALL RUSSELL HAVE ANY LIABILITY FOR ANY SPECIAL, PUNITIVE, INDIRECT, OR CONSEQUENTIAL DAMAGES (INCLUDING LOST PROFITS), EVEN IF NOTIFIED OF THE POSSIBILITY OF SUCH DAMAGES.]

	
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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 /TIN

	
Phone Number

	 	 
	 	
■  Contingent

	 	 	 	 	 	 	 
	 	
Individual First name

	
MI

	
Last Name

	
Date of birth (mm/dd/yyyy)

	
Gender

	 	 
	 	 	 	 	 	
■ Male    ■ Female

	 	 
	 	
■ Qualified plan

	
■ Custodian

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

	
■ Charitable Trust

	
Email

	 	 
	 	
Non-Individual Beneficiary name

	 	 	 	 	 
	 	 	 	 	 	 	 
	 	
Street Address

	
City

	
State

	
Zip Code

	 
	 	 	 	 	 	 
	 	
■  Primary

	 	
Percentage

	
Relationship

	
Social Security Number /TIN

	
Phone Number

	 	 
	 	
■  Contingent

	 	 	 	 	 	 	 
	 	
Individual First name

	
MI

	
Last Name

	
Date of birth (mm/dd/yyyy)

	
Gender

	 	 
	 	 	 	 	 	
■ Male    ■ Female

	 	 
	 	
■ Qualified plan

	
■ Custodian

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

	
■ Charitable Trust

	
Email

	 	 
	 	
Non-Individual Beneficiary name

	 	 	 	 	 
	 	 	 	 	 	 	 
	 	
Street Address

	
City

	
State

	
Zip Code

	 
	 	
■  Primary

	 	
Percentage

	
Relationship

	
Social Security Number /TIN

	
Phone Number

	 	 
	 	
■  Contingent

	 	 	 	 	 	 	 
	 	
Individual First name

	
MI

	
Last Name

	
Date of birth (mm/dd/yyyy)

	
Gender

	 	 
	 	 	 	 	 	
■ Male    ■ Female

	 	 
	 	
■ Qualified plan

	
■ Custodian

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

	
■ Charitable Trust

	
Email

	 	 
	 	
Non-Individual Beneficiary name

	 	 	 	 	 
	 	 	 	 	 	 	 
	 	
Street Address

	
City

	
State

	
Zip Code

	 

	
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		[9].	Financial Professional

Notice to Financial Professional: Product training has been completed that is applicable 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

	
B/D Rep. ID

	 
	 	 	 	 	 
	 	
Financial Professional's first and last name (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 address

	
Financial Professional's telephone number

	 
	 	 	 	 	 
	 	 	 	 	 

	 	
Broker/dealer name (please print)

 

	 
	 	
Authorized signature broker/dealer (if required)

 

	 

	 	 	 	 
	 	
Commission options

■ A   ■ B   ■ C

	 	 
	 	 	 	 

		[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.

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, you must cross out item 2 below.

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.I am exempt from Foreign Account Tax Compliance Act (FATCA) reporting.

The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.]

	
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		[11].	Statement of Owner

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

Alabama, Arkansas, Massachusetts, Rhode Island and West Virginia: 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.

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, fines, 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.

New Mexico: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FEAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURNACE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL 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.

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.

	•	If this contract is being funded by an indirect rollover, I have complied with the requirement that only on 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].

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, State)

	 
	 	 
	
Contract owner's signature:_________________________________________________

	
Date: ________________________

	 	
MMDD/YYYY

	 	 
	
Joint contract owner's signature: ____________________________________________

	
Date: ________________________

	 	
MMDD/YYYY

	 	 
	
Alternate signatures, if applicable

	 
	 	 
	
Trust:__________________________

	
As trustee of the:_________________________

	
Date: ________________________

	
TRUSTEE'S SIGNATURE

	
TRUST NAME(PRINTED)

	
MMDD/YYYY

	 	 	 
	
Power of attorney:_________________

	
By: ____________________________________

	
Date: ________________________

	
CONTRACT OWNER'S NAME (PRINTED)

	
ATTORNEY IN FACT'S SIGNATLURE(S)

	
MMDD/YYYY

	 	 	 

	
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Please submit your form through one of the options below:

	 
	
Email completed forms to:

	
[variableannuity@send.allianzlife.com]

	 
	
OR

	 
	
Web 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 mail

	
[Overnight mail

	
Allianz Life Insurance Company of North America

	
Allianz Life Insurance Company of North America

	
NW 5989

	
NW 5989

	
PO Box 1450

	
1801 Parkview Drive

	
Minneapolis, MN 55485-5989]

	
Shoreview, MN 55126]

	 	 
	
OR

	 
	 	 
	
Applications that DO NOT HAVE a check attached:

	 
	
[Regular mail

	
[Overnight mail

	
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]

	 	 
	
OR

	 
	 	 
	
[Fax: 763.765.7912]

	 
	 	 
	
[Any questions? Call us at 800.624.0197]

	 
	 	 

	
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[(5/2015)]EX-10.1

 Exhibit 10.1 

BRASA (PARENT) INC. 

2012 OMNIBUS EQUITY INCENTIVE PLAN 
  

	Article 1.	Establishment & Purpose 

1.1        Establishment.    Brasa (Parent) Inc., a Delaware corporation
(the “Company”), hereby establishes the 2012 Omnibus Equity Incentive Plan (this “Plan”) as set forth herein. 

1.2        Purpose of this Plan.    The purpose of this Plan is to attract,
retain and motivate the officers, directors, employees and consultants of the Company and its Subsidiaries and Affiliates, and to promote the success of the Company’s business by providing them with appropriate incentives and rewards either
through a proprietary interest in the long-term success of the Company or compensation based on fulfilling certain performance goals. The Plan is a “compensatory benefit plan” within the meaning of Rule 701 under the Securities Act of 1933
(the “Securities Act”), as amended, and all Awards granted under the Plan are intended to qualify for an exemption from the registration requirements (i) under the Securities Act, pursuant to Rule 701 of the Securities Act
and (ii) under applicable state securities laws.
  

	Article 2.	Definitions 

 Capitalized terms used and not otherwise defined herein shall have the
meanings set forth below. 
 2.1        “THL Stockholders” has the
meaning set forth in the Stockholders Agreement. 

2.2        “Affiliate” means, with respect to any specified Person, any
other Person which, directly or indirectly, through one or more intermediaries, controls, or is controlled by, or is under common control with, such specified Person (for the purposes of this definition, “control” (including, with
correlative meanings, the terms “controlling,” “controlled by” and “under common control with”), as used with respect to any Person, means the possession, directly or indirectly, of the power to
direct or cause the direction of the management or policies of such Person, whether through the ownership of voting securities, by agreement or otherwise); provided, however, that for purposes of this Agreement the Company and its
Subsidiaries shall not be an Affiliate of any Stockholder or of any Stockholder’s Affiliates. Unless otherwise specifically indicated, when used herein the term Affiliate shall refer to an Affiliate of the Company. 

2.3        “Award” means any Option, Stock Appreciation Right,
Restricted Stock, or Other Stock-Based Award that is granted under this Plan. 

2.4        “Award Agreement” means either (a) a written agreement
entered into by the Company and a Participant setting forth the terms and provisions applicable to an Award, or (b) a written statement signed by an authorized officer of the Company to a Participant describing the terms and provisions of the
actual grant of such Award. 
 2.5        “Board” means the Board of
Directors of the Company. 
 2.6        “Cause” means: (i) with
respect to any Participant who is employed by the Company or one of its Affiliates pursuant to an effective written employment agreement, if any, between the Company and/or one of its Affiliates and such Participant in which there is a definition of
“Cause,” in which event the definition of “Cause” as set forth in such employment agreement shall be deemed to be the definition of “Cause” herein solely for such Participant and only for so long as such employment
agreement remains effective, or (ii) except as otherwise expressly provided in an Award Agreement, the term “Cause” means 

 
such Participant’s: (a) misappropriation or theft of the Company’s or any of its Affiliates’ funds or property; (b) indictment for, conviction of or entering of a plea of
nolo contendere of any fraud, misappropriation, embezzlement or similar act, felony or crime involving dishonesty or moral turpitude; (c) material breach of the Award Agreement or failure to perform any of the Participant’s material
duties owed to the Company; or (d) commission of any act involving willful malfeasance or gross negligence or the Participant’s failure to act involving material nonfeasance; provided, however, that, in the case of the above
sub-clause (c), termination of Service by the Company or the Company’s Affiliate, if applicable, shall not be for “Cause” unless (i) such breach is not capable of being cured, or (ii) such Participant has first been given
written notice of such breach by the Company or its Affiliate, as applicable, and, if such breach is capable of being cured, such breach remains uncured for a period of ten (10) business days after such notice to the Participant or, if cured,
recurs within 180 days. 
 2.7        “Change of Control” unless
otherwise specified in the Award Agreement, means any transaction or a series of related transactions as a result of which any Person or group of Persons other than the THL Stockholders, shall (A) acquire (whether by purchase, exchange, tender
offer, merger, consolidation, recapitalization, redemption, reorganization, issuance of capital stock or otherwise) directly or indirectly more than 50% of the voting power of the Company or more than 50% of Common Stock Equivalents (as defined in
the Stockholders Agreement) that were issued and outstanding immediately prior to such transaction or series of transactions, or (B) acquire assets constituting all or substantially all of the assets of the Company and its Subsidiaries on a
consolidated basis. A “group of Persons” shall have the same meaning given as when such phrase is used with respect to Section 13(d) of the Securities Exchange Act of 1934, as amended. 

To the extent necessary to comply with Section 409A of the Code with respect to the payment of deferred compensation, “Change of Control” shall
be limited to a “change in control event” as defined in Treasury Regulations Section 1.409A-3(i)(5) prescribed pursuant to Section 409A of the Code. 

2.8        “Code” means the U.S. Internal Revenue Code of 1986, as
amended from time to time. 
 2.9        “Committee” means the Board,
or any committee designated by the Board to administer this Plan in accordance with Article 3 of this Plan. 

2.10      “Consultant” means any person who provides bona fide services to the
Company or any Affiliate or Subsidiary as a consultant or advisor, excluding any Employee or Director. 

2.11      “Director” means a member of the Board who is not an Employee. 

2.12      “Employee” means an officer or other employee of the Company or any
Subsidiary or Affiliate, including a member of the Board who is such an employee. 

2.13      “Fair Market Value” means, as of any day, with respect to the Shares:

  

	 	(a)	if the Shares are immediately and freely tradable on a stock exchange or in over-the-counter market, the closing price per Share on the preceding day, or if no trades were made on such date, the immediately preceding
day on which trades were made; or 

  

	 	(b)	in the absence of such a market for the Shares, the fair value per Share as determined in good faith by the Board and, for the purpose of determining the Option Price or grant price of an Award, consistent with the
principles of Section 409A of the Code. 

  
 2 

 2.14      “Good Reason” shall have
the meaning set forth below, except with respect to any Participant who is employed by the Company or one of its Affiliates pursuant to an effective written employment agreement, if any, between the Company and/or one of its Affiliates and such
Participant in which there is a definition of “Good Reason,” in which event the definition of “Good Reason” as set forth in such employment agreement shall be deemed to be the definition of “Good Reason” herein solely
for such Participant and only for so long as such employment agreement remains effective. In all other events, the term “Good Reason” shall mean the following: (a) a material diminution of Participant’s base salary, (b) a
material diminution in the Participant’s authority, duties or responsibilities, or (c) the Company or any Affiliate requiring the Participant to be based at any office or location that is more than fifty (50) miles from the initial
location of the Participant’s employment. 
 2.15      “Incentive Stock
Option” means an Option intended to meet the requirements of an incentive stock option as defined in Section 422 of the Code and designated as an Incentive Stock Option in accordance with Article 6 of this Plan. 

2.16      “Nonqualified Stock Option” means an Option that is not an Incentive
Stock Option. 
 2.17      “Option” means any Option granted from time to time
under Article 6 of this Plan. 
 2.18      “Option Price” means the
purchase price per Share subject to an Option, as determined pursuant to Section 6.2 of this Plan. 

2.19      “Other Stock-Based Award” means any Award granted under Article 9
of this Plan. 
 2.20      “Participant” means any eligible person as set forth
in Section 4.1 to whom an Award is granted. 
 2.21      “Permanent
Disability” shall have the meaning set forth below, except with respect to any Participant who is employed by the Company or one of its Affiliates pursuant to an effective written employment agreement, if any, between the Company and/or
one of its Affiliates and such Participant in which there is a definition of “Permanent Disability,” in which event the definition of “Permanent Disability” as set forth in such employment agreement shall be deemed to be the
definition of “Permanent Disability” herein solely for such Participant and only for so long as such employment agreement remains effective. In all other events, the term “Permanent Disability” shall mean: a determination by
independent competent medical authority (selected by the Board) that the Participant is unable to perform his duties and in all reasonable medical likelihood such inability shall continue for a consecutive period of 90 days or for a period in excess
of 120 days in any 365 day period. 
 2.22      “Person” means any natural
person, sole proprietorship, general partnership, limited partnership, limited liability company, joint venture, trust, unincorporated organization, association, corporation, governmental authority, or any other organization, irrespective of whether
it is a legal entity and includes any successor (by merger or otherwise) of such entity. 

2.23      “Restricted Stock” means any Award granted under Article 8 of
this Plan. 
 2.24      “Restriction Period” means the period during which
Restricted Stock awarded under Article 8 of this Plan is restricted. 

2.25      “Service” means service as an Employee, Director or Consultant. 

  
 3 

 2.26      “Share” means a share of
common stock of the Company, par value $0.01 per share, or such other class or kind of shares or other securities resulting from the application of Article 11 of this Plan. 

2.27      “Stock Appreciation Right” means any right granted under Article
7 of this Plan 
 2.28      “Stockholders” has the meaning set forth in the
Stockholders Agreement. 
 2.29      “Stockholders Agreement” means that certain
Brasa (Parent) Inc. Stockholders Agreement dated July     , 2012 entered into by and among the Company and the stockholders listed on the signature pages thereto, as may be amended from time to time. 

2.30      “Subsidiary” with respect to any entity (the “parent”) means
any corporation, limited liability company, company, firm, association or trust of which such parent, at the time in respect of which such term is used, (i) owns directly or indirectly more than fifty percent (50%) of the equity,
membership interest or beneficial interest, on a consolidated basis, or (ii) owns directly or controls with power to vote, directly or indirectly through one or more Subsidiaries, shares of the equity, membership interest or beneficial interest
having the power to elect more than fifty percent (50%) of the directors, trustees, managers or other officials having powers analogous to that of directors of a corporation. Unless otherwise specifically indicated, when used herein the term
Subsidiary shall refer to a direct or indirect Subsidiary of the Company. 
 2.31      “Ten
Percent Shareholder” means a person who on any given date owns, either directly or indirectly (taking into account the attribution rules contained in Section 424(d) of the Code), stock possessing more than ten percent (10%) of
the total combined voting power of all classes of stock of the Company or a Subsidiary or Affiliate. 
  

	Article 3.	Administration 

 3.1        Authority of the
Committee.    This Plan shall be administered by the Committee, which shall have full power to interpret and administer this Plan and full authority to select the Directors, Employees and Consultants to whom Awards will be
granted and determine the type and amount of Awards to be granted to each such Director, Employee or Consultant, the terms and conditions of such Awards. Without limiting the generality of the foregoing, the Committee may, in its sole discretion,
interpret, clarify, construe or resolve any ambiguity in any provision of this Plan or any Award Agreement, accelerate or waive vesting of Awards and exercisability of Awards, extend the term or period of exercisability of any Awards, modify the
purchase price or Option Price of any Award, or waive any terms or conditions applicable to any Award, subject to the limitations set forth in Section 12.2 of this Plan. Awards may, in the discretion of the Committee, be made under this
Plan in assumption of, or in substitution for, outstanding awards previously granted by the Company or an Affiliate or a company acquired by the Company or with which the Company combines. The Committee shall have full and exclusive discretionary
power to adopt rules, forms, instruments and guidelines for administering this Plan as the Committee deems necessary or proper. All actions taken and all interpretations and determinations made by the Committee or by the Board (or any other
committee or sub-committee thereof), as applicable, shall be final, binding and conclusive upon the Participants, the Company and all other interested individuals. 

3.2        Delegation.    The Committee may delegate to one or more of its
members, one or more officers of the Company or any Affiliate, or one or more agents or advisors such administrative duties or powers as it may deem advisable. 

  
 4 

	Article 4.	Eligibility and Participation 

4.1        Eligibility.    Participants will consist of such Employees,
Directors and Consultants as the Committee in its sole discretion determines and whom the Committee may designate from time to time to receive Awards under this Plan; provided, however, that Options and Stock Appreciation Rights may
only be granted to those Employees, Directors and Consultants with respect to whom the Company is an “eligible issuer” within the meaning of Section 409A of the Code. Designation of a Participant in any year shall not require the
Committee to designate such person to receive an Award in any other year or, once designated, to receive the same type or amount of Award as granted to the Participant in any other year. 

4.2        Type of Awards.    Awards under this Plan may be granted in any
one or a combination of: (a) Options; (b) Stock Appreciation Rights; (c) Restricted Stock; and (d) Other Stock-Based Awards. Awards granted under this Plan shall be evidenced by Award Agreements (which need not be identical) that
provide additional terms and conditions associated with such Awards, including, without limitation restrictive covenants, as determined by the Committee in its sole discretion; provided, however, that in the event of any conflict
between the provisions of this Plan and any such Award Agreement, the provisions of this Plan shall prevail. 
  

	Article 5.	Shares Subject to this Plan and Maximum Awards 

5.1        Number of Shares Available for Awards. 

 

	 	(a)	Shares.    Subject to adjustment as provided in this Article 5 and Article 11 of the Plan, the maximum number of Shares available for issuance to Participants pursuant to Awards,
other than Restricted Stock issued in connection with the transactions contemplated by the Merger Agreement (as defined in the Stockholders Agreement), under the Plan shall be 90,000, and the maximum number of Shares available for issuance of
Restricted Stock issued in connection with the transactions contemplated by the Merger Agreement under the Plan shall be         . The Shares available for issuance under the Plan may consist, in whole
or in part, of authorized and unissued Shares or treasury Shares. Any Shares tendered to or withheld by the Company as part or full payment for the purchase price, Option Price or grant price of an Award or to satisfy all or part of the
Company’s tax withholding obligation with respect to an Award shall not be available for the issuance of additional Awards. 

  

	 	(b)	Additional Shares.    In the event that any outstanding Award, other than Restricted Stock issued in connection with the transactions contemplated by the Merger Agreement, expires, is
forfeited, cancelled or otherwise terminated without consideration (i.e., Shares or cash) therefor, the Shares subject to such Award, to the extent of any such forfeiture, cancellation, expiration, termination or settlement, shall again be available
for Awards under this Plan. If the Committee authorizes the assumption under this Plan, in connection with any merger, consolidation, acquisition of property or stock, or reorganization, of awards granted under another plan, such assumption shall
not reduce the maximum number of Shares available for issuance under this Plan. 

  

	Article 6.	Options 

 6.1        Grant of
Options.    The Committee is hereby authorized to grant Options to Participants. Each Option shall permit a Participant to purchase from the Company a stated number of Shares at an Option Price established by the Committee,
subject to the 

  
 5 

 
terms and conditions described in this Article 6 and to such additional terms and conditions, as established by the Committee, in its sole discretion, that are consistent with the
provisions of the Plan. Options shall be designated as either Incentive Stock Options or Nonqualified Stock Options; provided, that, Options granted to Directors shall be Nonqualified Stock Options. An Option granted as an Incentive
Stock Option shall, to the extent it fails to qualify under the Code as an Incentive Stock Option, be treated as a Nonqualified Stock Option. Neither the Committee, the Company, any of its Subsidiaries or Affiliates, nor any of their employees or
representatives shall be liable to any Participant or to any other Person if it is determined that an Option intended to be an Incentive Stock Option does not qualify under the Code as an Incentive Stock Option. Each Option shall be evidenced by an
Award Agreement which shall state the number of Shares covered by such Option. Such Award Agreements shall conform to the requirements of the Plan and may contain such other provisions as the Committee shall deem advisable. 

6.2        Option Price.    The Option Price shall be determined by the
Committee at the time of grant, but shall not be less than one-hundred percent of the Fair Market Value of a Share on the date of grant. In the case of any Incentive Stock Option granted to a Ten Percent Shareholder, the Option Price shall not be
less than one-hundred-ten percent of the Fair Market Value of a Share on the date of grant. 

6.3        Option Term.    The term of each Option shall be determined by
the Committee at the time of grant and shall be stated in the Award Agreement, but in no event shall such term be greater than ten years (or, in the case on an Incentive Stock Option granted to a Ten Percent Shareholder, five years). 

6.4        Time of Exercise.    Options granted under this Article 6
shall be exercisable at such times and be subject to such restrictions and conditions as the Committee shall in each instance approve as set forth in each Award Agreement, which terms and restrictions need not be the same for each grant or for each
Participant. 
 6.5        Method of Exercise.    Except as otherwise
provided in the Plan or in an Award Agreement, an Option may be exercised for all, or from time to time any part, of the Shares for which it is then exercisable. For purposes of this Article 6, the exercise date of an Option shall be the
later of the date a notice of exercise is received by the Company and, if applicable, the date full payment is received by the Company pursuant to clauses (a), (b), (c), (d), or (e) of the following sentence (including the applicable tax
withholding pursuant to Section 14.3 of the Plan). The aggregate Option Price for the Shares as to which an Option is exercised shall be paid to the Company in full at the time of exercise at the election of the Participant: (a) in
cash or its equivalent (e.g., by cashier’s check); (b) to the extent permitted by the Committee, in Shares (whether or not previously owned by the Participant) having a Fair Market Value equal to the aggregate Option Price for the Shares
being purchased and satisfying such other requirements as may be imposed by the Committee; (c) partly in cash and, to the extent permitted by the Committee, partly in such Shares (as described in (b) above); (d) to the extent
permitted by the Committee, by reducing the number of Shares otherwise deliverable upon the exercise of the Option by the number of Shares having a Fair Market Value equal to the Option Price; or (e) if there is a public market for the Shares
at such time, subject to such requirements as may be imposed by the Committee, through the delivery of irrevocable instructions to a broker to sell Shares obtained upon the exercise of the Option and to deliver promptly to the Company an amount out
of the proceeds of such sale equal to the aggregate Option Price for the Shares being purchased. The Committee may prescribe any other method of payment that it determines to be consistent with applicable law and the purpose of the Plan. 

6.6        Limitations on Incentive Stock Options.    Incentive Stock
Options may be granted only to employees of the Company or of a “parent corporation” or “subsidiary corporation” (as such terms are 

  
 6 

 
defined in Section 424 of the Code) at the date of grant. The aggregate Fair Market Value (generally determined as of the time the Option is granted) of the Shares with respect to which
Incentive Stock Options are exercisable for the first time by a Participant during any calendar year under all plans of the Company and of any “parent corporation” or “subsidiary corporation” shall not exceed one hundred thousand
dollars, or the Option shall be treated as a Nonqualified Stock Option, but only to the extent of that portion of the Option in excess of the limit. For purposes of the preceding sentence, unless otherwise designated by the Company, Incentive Stock
Options will be taken into account in the order in which they are granted. Each provision of the Plan and each Award Agreement relating to an Incentive Stock Option shall be construed so that each Incentive Stock Option shall be an incentive stock
option as defined in Section 422 of the Code, and any provisions of the Award Agreement thereof that cannot be so construed shall be disregarded. 
  

	Article 7.	Stock Appreciation Rights 

 7.1        Grant
of Stock Appreciation Rights.    The Committee is hereby authorized to grant Stock Appreciation Rights to Participants. Stock Appreciation Rights shall be evidenced by Award Agreements that shall conform to the requirements
of the Plan and may contain such other provisions as the Committee shall deem advisable. Subject to the terms of the Plan and any applicable Award Agreement, a Stock Appreciation Right granted under the Plan shall confer on the holder thereof a
right to receive, upon exercise thereof, the excess of: (a) the Fair Market Value of a specified number of Shares on the date of exercise over (b) the grant price of the right as specified by the Committee on the date of the grant. Such
payment may be in the form of cash, Shares, other property or any combination thereof, as the Committee shall determine in its sole discretion. 

7.2        Terms of Stock Appreciation Right.    Each Stock Appreciation
Right grant shall be evidenced by an Award Agreement which shall state the grant price (which shall not be less than one-hundred percent of the Fair Market Value of a Share on the date of grant), term, methods of exercise, methods of settlement, and
such other provisions as the Committee shall determine. No Stock Appreciation Right shall have a term of more than ten years from the date of grant. 
  

	Article 8.	Restricted Stock 

 8.1        Grant of
Restricted Stock.    The Committee is hereby authorized to grant Restricted Stock to Participants. An Award of Restricted Stock is a grant by the Committee of a specified number of Shares to the Participant, which Shares are
subject to forfeiture upon the occurrence of specified events. Participants shall be awarded Restricted Stock in exchange for consideration not less than the minimum consideration required by applicable law. Restricted Stock shall be evidenced by an
Award Agreement, which shall conform to the requirements of the Plan and may contain such other provisions as the Committee shall deem advisable. 

8.2        Terms of Restricted Stock Awards.    Each Award Agreement
evidencing a Restricted Stock grant shall specify the Restriction Period(s), the number of Shares of Restricted Stock subject to the Award, the purchase price, if any, of the Restricted Stock, the performance, employment, or other conditions
(including the termination of a Participant’s Service whether due to death, disability or other reason) under which the Restricted Stock may be forfeited to the Company and such other provisions as the Committee shall determine. Any Restricted
Stock granted under the Plan shall be evidenced in such manner as the Committee may deem appropriate, including book-entry registration or issuance of a stock certificate or certificates (in which case, the certificate(s) representing such Shares
shall be legended as to sale, transfer, assignment, pledge or other encumbrances during the Restriction Period and deposited by the Participant, together with a stock power endorsed in blank, with the Company, to be held in escrow during the
Restriction Period). At the end of the Restriction Period, the restrictions imposed hereunder 

  
 7 

 
and under the Award Agreement shall lapse with respect to the number of Shares of Restricted Stock as set forth in the applicable Award Agreement, and, except as provided in
Section 14.6, the legend required by this Section 8.2 shall be removed and such number of Shares delivered to the Participant (or, where appropriate, the Participant’s legal representative). 

8.3        Voting and Dividend Rights.    The Committee shall determine and
set forth in a Participant’s Award Agreement whether or not a Participant holding Restricted Stock granted hereunder shall have the right to exercise voting rights with respect to the Restricted Stock during the Restriction Period (the
Committee may require a Participant to grant an irrevocable proxy and power of substitution) and/or have the right to receive dividends on the Restricted Stock during the Restriction Period (and, if so, on what terms). 

8.4        Performance Goals.    The Committee may condition the grant of
Restricted Stock or the expiration of the Restriction Period upon the Participant’s achievement of one or more performance goal(s) specified in the Award Agreement. If the Participant fails to achieve the specified performance goal(s), the
Committee shall not grant the Restricted Stock to such Participant or the Participant shall forfeit the Award of Restricted Stock to the Company, as applicable. 

8.5        Section 83(b) Election.    If a Participant makes an
election pursuant to Section 83(b) of the Code concerning Restricted Stock, the Participant shall be required to file promptly a copy of such election with the Company. 
  

	Article 9.	Other Stock-Based Awards 

 The Committee, in its sole discretion, may grant Awards of
Shares and Awards that are valued, in whole or in part, by reference to, or are otherwise based on the Fair Market Value of, Shares, including without limitation, restricted stock units, dividend equivalent rights, and other phantom awards. Such
Other Stock-Based Awards shall be in such form, and dependent on such conditions, as the Committee shall determine, including, without limitation, the right to receive one or more Shares (or the equivalent cash value of such Shares) upon the
completion of a specified period of Service, the occurrence of an event, and/or the attainment of performance objectives. Subject to the provisions of the Plan, the Committee shall determine to whom and when Other Stock-Based Awards will be made,
the number of Shares to be awarded under (or otherwise related to) such Other Stock-Based Awards, whether such Other Stock-Based Awards shall be settled in cash, Shares or a combination of cash and Shares, and all other terms and conditions of such
Awards (including, without limitation, the vesting provisions thereof and provisions ensuring that all Shares so awarded and issued shall be fully paid and non-assessable). Each Other Stock-Based Award grant shall be evidenced by an Award Agreement,
which shall conform to the requirements of the Plan. 
  

	Article 10.	Compliance with Section 409A of the Code 

10.1      General.    The Company intends that the Plan and all Awards be construed to
avoid the imposition of additional taxes, interest, and penalties pursuant to Section 409A of the Code (together with all regulations, guidance, compliance programs, and other interpretative authority thereunder (“Section
409A”). Notwithstanding the Company’s intention, in the event any Award is subject to such additional taxes, interest or penalties pursuant to Section 409A, the Committee may, in its sole discretion and without a
Participant’s prior consent, amend the Plan and/or Awards, adopt policies and procedures, or take any other actions (including amendments, policies, procedures and actions with retroactive effect) as are necessary or appropriate to
(a) exempt the Plan and/or any Award from the application of Section 409A, (b) preserve the intended tax treatment of any such Award, or (c) comply with the requirements of Section 409A, including without limitation any such
regulations, guidance, compliance programs, and 

  
 8 

 
other interpretative authority that may be issued after the date of the grant. In no event shall the Company or any of its Subsidiaries or Affiliates be liable for any additional tax, interest or
penalties that may be imposed on a Participant under Section 409A or any damages for failing to comply with Section 409A. 

10.2      Payments to Specified Employees.    Notwithstanding any contrary provision
in the Plan or Award Agreement, any payment(s) of nonqualified deferred compensation (within the meaning of Section 409A) that are otherwise required to be made under the Plan to a “specified employee” (as defined under
Section 409A) as a result of his or her separation from service (other than a payment that is not subject to Section 409A) shall be delayed for the first six months following such separation from service (or, if earlier, until the date of
death of the specified employee) and shall instead be paid (in a manner set forth in the Award Agreement) on the day that immediately follows the end of such six-month period or as soon as administratively practicable thereafter. Any remaining
payments of nonqualified deferred compensation shall be paid without delay and at the time or times such payments are otherwise scheduled to be made. 

10.3      Separation from Service.    A termination of Service shall not be deemed to
have occurred for purposes of any provision of the Plan or any Award Agreement providing for the payment of any amounts or benefits that are considered nonqualified deferred compensation under Section 409A upon or following a termination of
Service, unless such termination is also a “separation from service” within the meaning of Section 409A and the payment thereof prior to a “separation from service” would violate Section 409A. For purposes of any such
provision of the Plan or any Award Agreement relating to any such payments or benefits, references to a “termination,” “termination of employment,” “termination of service,” or like terms shall mean “separation
from service.” 
  

	Article 11.	Adjustments 

 11.1      Adjustments in Authorized
Shares.    In the event of any corporate event or transaction involving the Company, a Subsidiary and/or an Affiliate (including, but not limited to, a change in the Shares of the Company or the capitalization of the Company)
such as a merger, consolidation, reorganization, recapitalization, separation, stock dividend, stock split, reverse stock split, split up, spin-off, combination of Shares, exchange of Shares, dividend in kind, extraordinary cash dividend,
amalgamation, or other like change in capital structure (other than normal cash dividends to stockholders of the Company), or any similar corporate event or transaction, the Committee, to prevent dilution or enlargement of Participants’ rights
under the Plan, shall substitute or adjust, in its sole discretion, the number and kind of Shares or other property that may be issued under the Plan or under particular forms of Awards, the number and kind of Shares or other property subject to
outstanding Awards, the Option Price, grant price or purchase price applicable to outstanding Awards and/or other value determinations (including performance conditions) applicable to the Plan or outstanding Awards. All adjustments shall be made in
good faith compliance with Section 409A. For the avoidance of doubt, the purchase of Shares or other equity securities of the Company by a stockholder of the Company or any third party from the Company shall not constitute a corporate event or
transaction giving rise to an adjustment described in this Section 11.1. 
 11.2      Change of
Control.    Upon the occurrence of a Change of Control after the Effective Date, unless otherwise specifically prohibited under applicable laws or by the rules and regulations of any governing governmental agencies or
national securities exchanges, or unless the Committee shall specify otherwise in the Award Agreement, the Committee is authorized (but not obligated) to make adjustments in the terms and conditions of outstanding Awards, including without
limitation the following (or any combination thereof): (a) continuation or assumption of such outstanding Awards under the Plan by the Company (if it is the surviving company or corporation) or by the surviving company or corporation or its
parent; (b) substitution by the surviving company or corporation or its parent of awards with substantially 

  
 9 

 
the same terms for outstanding Awards (excluding the consideration payable upon settlement of the Awards); (c) accelerated exercisability, vesting and/or lapse of restrictions under
outstanding Awards immediately prior to the occurrence of such event; (d) upon written notice, provide that any outstanding Awards must be exercised, to the extent then exercisable, during a reasonable period of time immediately prior to the
scheduled consummation of the event or such other period as determined by the Committee (contingent upon the consummation of the event), and at the end of such period, such Awards shall terminate to the extent not so exercised within the relevant
period; (e) cancellation of all or any portion of outstanding Awards for fair value (in the form of cash, Shares, other property or any combination thereof) as determined in the sole discretion of the Committee and which value may be zero;
provided, that, in the case of Options and Stock Appreciation Rights or similar Awards, the fair value may equal the excess, if any, of the value of the consideration to be paid in the Change of Control transaction to holders of the
same number of Shares subject to such Awards (or, if no such consideration is paid, Fair Market Value of the Shares subject to such outstanding Awards or portion thereof being canceled) over the aggregate Option Price or grant price, as applicable,
with respect to such Awards or portion thereof being canceled, or if no such excess, zero; and (f) cancellation of all or any portion of outstanding unvested and/or unexercisable Awards for no consideration. 

 

	Article 12.	Duration; Amendment, Modification, Suspension and Termination 

12.1      Duration of Plan.    Unless sooner terminated as provided in
Section 12.2, this Plan shall terminate on the tenth (10th) anniversary of the Effective Date. 

12.2      Amendment, Modification, Suspension and Termination of Plan.    Subject to
the terms of the Plan, the Committee may amend, alter, suspend, discontinue or terminate this Plan or any portion thereof or any Award (or Award Agreement) hereunder at any time, in its sole discretion, provided, that, no action taken
by the Committee shall adversely affect the rights granted to any Participant under any outstanding Awards (other than pursuant to Article 10, Article 11, or as the Committee deems necessary to comply with applicable law, including
without limitation, the Dodd-Frank Wall Street Reform and Consumer Protection Act) without the Participant’s written consent. 
  

	Article 13.	Forfeiture of Awards Upon Termination of Service 

13.1      Termination of Service for Cause.    Unless otherwise provided in an Award
Agreement, in the event (a) a Participant’s Service is terminated for Cause, (b) the Participant’s Service is terminated due to the Participant’s resignation after an inquiry by the Board as to the existence of Cause has
been initiated and the Board determines that Cause existed as of the date of such resignation, or (c) the Board determines that a Participant’s acts or omissions constitute Cause, all outstanding Awards held by the Participant shall
terminate and be forfeited without consideration, effective on the date the Participant’s Service is terminated for Cause or the date the act or omission constituting Cause is determined to have occurred, as applicable. 

13.2      Termination of Service Due to Death or Disability.    Unless otherwise
provided in an Award Agreement, in the event a Participant’s Service is terminated due to death or Disability (and Cause does not exist as of such date): (a) all unvested Awards held by the Participant shall terminate and be forfeited
without consideration, effective as of the date the Participant’s Service is terminated and (b) all vested Options and Stock Appreciation Rights shall terminate on the earlier of (i) one (1) year following the termination of
Service and (ii) the expiration of the term of such Options and Stock Appreciation Rights. 

13.3      Termination of Service for Reason Other than Cause, Death or
Disability.    Unless otherwise provided in an Award Agreement, in the event a Participant’s Service is terminated for any 

  
 10 

 
reason other pursuant to Section 13.1 and Section 13.2 above (and Cause does not exist as of such date): (a) all unvested Awards held by the Participant shall
terminate and be forfeited without consideration, effective as of the date the Participant’s Service is terminated and (b) all vested Options and Stock Appreciation Rights shall terminate on the earlier of (i) ninety (90) days
following the termination of Service and (ii) the expiration of the term of such Options and Stock Appreciation Rights. 
  

	Article 14.	General Provisions 

 14.1      No Right to Service or
Award.    The granting of an Award under the Plan shall impose no obligation on the Company, any Subsidiary or any Affiliate to continue the Service of a Participant and shall not lessen or affect any right that the Company,
any Subsidiary or any Affiliate may have to terminate the Service of such Participant. No Participant or other Person shall have any claim to be granted any Award, and there is no obligation for uniformity of treatment of Participants, or holders or
beneficiaries of Awards. The terms and conditions of Awards and the Committee’s determinations and interpretations with respect thereto need not be the same with respect to each Participant (whether or not such Participants are similarly
situated). 
 14.2      Settlement of Awards.    Each Award Agreement shall
establish the form in which the Award shall be settled. The Committee shall determine whether cash, Awards, other securities or other property shall be issued or paid in lieu of fractional Shares or whether such fractional Shares or any rights
thereto shall be issued, rounded, forfeited, or otherwise eliminated. 
 14.3      Tax
Withholding.    The Company shall have the power and the right to deduct or withhold automatically from any amount deliverable under the Award or otherwise, or require a Participant to remit to the Company, the minimum
statutory amount to satisfy federal, state, and local taxes, domestic or foreign, required by law or regulation to be withheld with respect to any taxable event arising as a result of the Plan. The Committee, in its sole discretion, may permit
Participants to satisfy the withholding requirement, in whole or in part, by having the Company withhold Shares having a Fair Market Value equal to the minimum statutory total tax that could be imposed in connection with any such taxable event. 

14.4      No Guarantees Regarding Tax Treatment.    Participants (or their
beneficiaries) shall be responsible for all taxes with respect to any Awards under the Plan. The Committee and the Company make no guarantees to any Person regarding the tax treatment of Awards or payments made under the Plan. Neither the Committee
nor the Company has any obligation to take any action to prevent the assessment of any tax on any Person with respect to any Award under Section 409A of the Code or Section 457A of the Code or otherwise and none of the Company, any of its
Subsidiaries or Affiliates, or any of their employees or representatives shall have any liability to a Participant with respect thereto. 

14.5      Non-Transferability of Awards.    Unless otherwise determined by the
Committee, an Award shall not be transferable or assignable by the Participant except in the event of his death (subject to the applicable laws of descent and distribution) and any such purported assignment, alienation, pledge, attachment, sale,
transfer or encumbrance shall be void and unenforceable against the Company or any Affiliate. No transfer shall be permitted for value or consideration. An award exercisable after the death of a Participant may be exercised by the heirs, legatees,
personal representatives or distributees of the Participant. Any permitted transfer of the Awards to heirs, legatees, personal representatives or distributees of the Participant shall not be effective to bind the Company unless the Committee shall
have been furnished with written notice thereof and a copy of such evidence as the Committee may deem necessary to establish the validity of the transfer and the acceptance by the transferee or transferees of the terms and conditions hereof. 

  
 11 

 14.6      Stockholders Agreement; Conditions and Restrictions on
Shares.    Shares received in connection with Awards granted hereunder shall be subject to all of the terms and conditions of the Stockholders Agreement, including all transfer restrictions, repurchase rights and “take
along” rights set forth therein. As a condition to receiving, exercising or settling an Award, if not already fully bound by the terms set forth in the Stockholders Agreement, each Participant shall sign a joinder agreement pursuant to which
such Participant shall become fully bound by the terms set forth in the Stockholders Agreement. The Committee may impose such other conditions or restrictions on any Shares received in connection with an Award as it may deem advisable or desirable.
These restrictions may include, but shall not be limited to, requirements that the Participant: (a) hold the Shares received for a specified period of time or (b) represent and warrant in writing that the Participant is acquiring the
Shares for investment and without any present intention to sell or distribute such Shares. The certificates for Shares may include any legend which the Committee deems appropriate to reflect any conditions and restrictions applicable to such Shares.

 14.7      Shares Not Registered.    Shares and Awards shall be issued under this
Plan unless the issuance and delivery of such Shares and any Awards will not, in the opinion of counsel, comply with (unless exempt from) all applicable requirements of law, including, without limitation, the Securities Act of 1933, as amended, the
rules and regulations promulgated thereunder, state securities laws and regulations, and the regulations of any stock exchange or other securities market on which the Company’s securities may then be traded. The Company shall not be obligated
to file any registration statement under any applicable securities laws to permit the purchase or issuance of any Shares or any Awards under this Plan, and accordingly any certificates for Shares or documents granting Awards may have an appropriate
legend or statement of applicable restrictions endorsed thereon. If the Company deems it necessary to ensure that the issuance of securities under this Plan is not required to be registered under any applicable securities laws, each Participant to
whom such security would be purchased or issued shall deliver to the Company an agreement or certificate containing such representations, warranties and covenants as the Company reasonably requires. 

14.8      Awards to Non-U.S. Employees or Directors.    To comply with the laws in
countries other than the United States in which the Company or any Subsidiary or Affiliate operates or has Employees, Directors or Consultants, the Committee, in its sole discretion, shall have the power and authority to: (a) determine which
Subsidiaries or Affiliates shall be covered by the Plan; (b) determine which Employees, Directors or Consultants outside the United States are eligible to participate in the Plan; (c) modify the terms and conditions of any Award granted to
Employees, Directors or Consultants outside the United States to comply with applicable foreign laws; (d) take any action, before or after an Award is made, that it deems advisable to obtain approval or comply with any necessary local
government regulatory exemptions or approvals; and (e) establish sub-plans and modify exercise procedures and other terms and procedures, to the extent such actions may be necessary or advisable. 

14.9      Rights as a Stockholder.    Except as otherwise provided herein or in the
applicable Award Agreement, a Participant shall have none of the rights of a stockholder with respect to Shares covered by any Award until the Participant becomes the record holder of such Shares. 

14.10    Severability.    If any provision of the Plan or any Award is or becomes or is deemed
to be invalid, illegal, or unenforceable in any jurisdiction, or as to any Person or Award, or would disqualify the Plan or any Award under any law deemed applicable by the Committee, such provision shall be construed or deemed amended to conform to
applicable laws, or if it cannot be so construed or deemed amended without, in the determination of the Committee, materially altering the intent of the Plan or the Award, such provision shall be stricken as to such jurisdiction, Person, or Award,
and the remainder of the Plan and any such Award shall remain in full force and effect. 

  
 12 

 14.11    Unfunded Plan.    Participants shall have
no right, title, or interest whatsoever in or to any investments that the Company or any of its Subsidiaries or Affiliates may make to aid it in meeting its obligations under the Plan. Nothing contained in the Plan, and no action taken pursuant to
its provisions, shall create or be construed to create a trust of any kind, or a fiduciary relationship between the Company and any Participant, beneficiary, legal representative, or any other Person. To the extent that any Person acquires a right
to receive payments from the Company under the Plan, such right shall be no greater than the right of an unsecured general creditor of the Company. All payments to be made hereunder shall be paid from the general funds of the Company and no special
or separate fund shall be established and no segregation of assets shall be made to assure payment of such amounts. The Plan is not subject to the U.S. Employee Retirement Income Security Act of 1974, as amended from time to time. 

14.12    No Constraint on Corporate Action.    Nothing in the Plan shall be construed to:
(a) limit, impair, or otherwise affect the Company’s right or power to make adjustments, reclassifications, reorganizations, or changes of its capital or business structure, or to merge or consolidate, or dissolve, liquidate, sell, or
transfer all or any part of its business or assets; or (b) limit the right or power of the Company to take any action which such entity deems to be necessary or appropriate. 

14.13    Successors.    All obligations of the Company under the Plan with respect to Awards
granted hereunder shall be binding on any successor to the Company, whether the existence of such successor is the result of a direct or indirect purchase, merger, consolidation, or otherwise, of all or substantially all of the business or assets of
the Company. 
 14.14    Governing Law.    This Plan and each Award Agreement and all claims
or causes of action or other matters (whether in contract, tort or otherwise) that may be based upon, arise out of or relate to this Plan or any Award Agreement or the negotiation, execution or performance of this Plan or any Award Agreement shall
be governed by and construed in accordance with the laws of the State of Delaware, excluding any conflict or choice of law rule or principle that might otherwise refer construction or interpretation of this Plan to the substantive law of another
jurisdiction. 
 14.15    Effective Date.    The Plan shall be effective as of the date of
adoption by the Board, which date is set forth below (the “Effective Date”). 

*                       
                 *                        
                * 
 This Plan was duly adopted and
approved by the Board of Directors of the Company on the 20th day of July, 2012. 

  
 13

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