C-Share Application Cover
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INDIVIDUAL FLEXIBLE PREMIUM
DEFERRED VARIABLE ANNUITY APPLICATION
The Guardian Insurance & Annuity Company, Inc. (GIAC)
Send application and check to:
Regular Mail:
The Guardian Insurance & Annuity Company, Inc.
Variable Annuity Administration
P.O. Box 26210
Lehigh Valley, PA 18002-6210
Express Mail:
The Guardian Insurance & Annuity Company, Inc.
Variable Annuity Administration
3900 Burgess Place
Bethlehem, PA 18017
Please type or print
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1. OWNER
Name ________________________________________________________________________
Address _____________________________________________________________________
City __________________________________ State _______________ Zip ___________
SS# or Tax ID#_______________________________________________________________
Sex: |_| M |_| F Date of Birth: Mo ___________ Day _______ Yr ____ Age _____
Tel: Day ____________________ Eve ___________________ E-mail ________________
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2. JOINT OWNER (if any)
Name ________________________________________________________________________
Relationship to Owner _______________________________________________________
Address _____________________________________________________________________
City __________________________________ State _______________ Zip ___________
SS# or Tax ID# _________________________________________ E-mail______________
Sex: |_| M |_| F Date of Birth: Mo ___________ Day _______ Yr ____ Age _____
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3. ANNUITANT (Complete only if different from owner in Section 1)
Name ________________________________________________________________________
Address _____________________________________________________________________
City __________________________________ State _______________ Zip ___________
SS# or Tax ID#_______________________________________________________________
Sex: |_| M |_| F Date of Birth: Mo ___________ Day _______ Yr ____ Age _____
Tel: Day _________________________________ Eve ______________________________
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4. CONTINGENT ANNUITANT (Optional Section - Available if owner is not the
annuitant)
Name ________________________________________________________________________
Address _____________________________________________________________________
City __________________________________ State _______________ Zip ___________
SS# or Tax ID#_______________________________________________________________
Sex: |_| M |_| F Date of Birth: Mo ___________ Day _______ Yr ____ Age _____
Tel: Day _________________________________ Eve ______________________________
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5. BENEFICIARY (If more than one, please indicate in whole %)
Beneficiary ______________________ Relationship to Annuitant_________________
Date of Birth: Mo ________ Day _________ Yr ___________ Age _________ _____%
Beneficiary ______________________ Relationship to Annuitant_________________
Date of Birth: Mo ________ Day _________ Yr ___________ Age _________ _____%
Beneficiary ______________________ Relationship to Annuitant_________________
Date of Birth: Mo ________ Day _________ Yr ___________ Age _________ _____%
Contingent Beneficiary ____________Relationship to Annuitant_________________
Date of Birth: Mo ________ Day _________ Yr ___________ Age _________ _____%
Contingent Beneficiary ____________Relationship to Annuitant_________________
Date of Birth: Mo ________ Day _________ Yr ___________ Age _________ _____%
Contingent Beneficiary ____________Relationship to Annuitant_________________
Date of Birth: Mo ________ Day _________ Yr ___________ Age _________ _____%
(Attach a separate sheet if necessary, signed and dated.)
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6. PLAN TYPE
|_| Non-Qualified |_| Traditional IRA |_| Roth IRA |_| Rollover IRA
|_| SEP IRA |_| SIMPLE IRA |_| 401(k) |_| TSA 403(b)
|_| 401(a) (Please indicate type of qualified plan)__________________________
|_| Other____________________________________________________________________
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7. ANNUITY COMMENCEMENT DATE
The Annuity Commencement Date will be the annuitant's 90th birthday. If you
want the Annuity Commencement Date to be other than this date, please notify
GIAC in writing.
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8. TELEPHONE TRANSFER AUTHORIZATION
|_| I have read the telephone transfer authorization rules in the
prospectus and elect telephone transfers.
|_| |_| |_| |_| |_|
Personal Security Code (Select any 5-digit number.)
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9. REPLACEMENT ANNUITY CONTRACT
Is this annuity intended to replace all or part of any other annuity contract
or life insurance policy? |_| Yes |_| No
If "Yes," complete any required replacement forms and provide the information
below on all contracts or policies to be replaced:
Insurer Name ________________________________________________________________
Owner Name __________________________________________________________________
Contract/Policy # ___________________________________________________________
(Attach a separate sheet if necessary.)
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10. STATEMENT OF ADDITIONAL INFORMATION
|_| Please send me a copy of the Statement of Additional Information to the
prospectus.
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11. OPTIONAL RIDERS (See prospectus for a description of the riders and annual
charges.)
|_| Contract Anniversary Enhanced Death Benefit Rider
|_| Living Benefit Rider (Please skip Section 12A, and complete Section 12B)
|_| Other___________________________________________________________________
|_| Other___________________________________________________________________
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12. PURCHASE PAYMENT/PAYMENT ALLOCATION
Complete Section A if you have not elected the Living Benefit Rider in
Section 11 above.
Complete Section B if you have elected the Living Benefit Rider in Section 11
above.
A. Purchase Payment/Payment Allocation:Contracts Without Living Benefit Rider
Purchase Payment: $________________ submitted with this application. Minimum
initial payment: [$500] (Please see prospectus for details.)
Payment Allocation: Maximum of [twenty] investments. WHOLE % ONLY (NO
FRACTIONS): MUST TOTAL 100%.
<TABLE>
<CAPTION>
GUARDIAN FIDELITY (continued)
<S> <C>
______% Guardian Stock Fund ______% Fidelity VIP Equity-Income Portfolio
______% Guardian Bond Fund ______% Fidelity VIP III Growth Portfolio
______% Guardian Cash Fund JANUS
______% Guardian Small Cap Stock Fund ______% Janus Aggressive Growth Portfolio
______% Guardian VC 500 Index Fund ______% Janus Capital Appreciation Portfolio
______% Guardian VC Asset Allocation Fund ______% Janus Flexible Income Portfolio
______% Guardian VC High Yield Bond Fund ______% Janus Growth & Income Portfolio
______% Baillie Gifford International Fund ______% Janus Worldwide Growth Portfolio
______% Baillie Gifford Emerging Markets Fund MFS
AIM ______% MFS Capital Opportunities Series
______% AIM V.I. Aggressive Growth Fund ______% MFS Emerging Growth Series
______% AIM V.I. Growth Fund ______% MFS Global Government Series
______% AIM V.I. Government Securities Fund ______% MFS Growth With Income Series
______% AIM V.I. Value Fund ______% MFS New Discovery Series
FIDELITY VALUE LINE
______% Fidelity Balanced Portfolio ______% Value Line Centurion Fund
______% Fidelity VIP II Contrafund Portfolio ______% Value Line Strategic Asset Management Trust
</TABLE>
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B. Purchase Payment/Payment Allocation:Contracts with the Living Benefit
Rider
Purchase Payment: $________________ submitted with this application. Minimum
initial payment: [$500] (Please see prospectus for details.)
o Complete below, adhering to the percentage requirement for each of the
four allocation classes. Be sure that each selection is a whole % only (no
fractions).
o The payment allocation must satisfy the Percentage Requirements for the
four Asset Allocation Classes: 10% Capital Preservation / 40% Income / 40%
Growth / 10% Aggressive Growth.
o Double-check to make sure the percentages add up to 100%.
o Also make sure that no more than [20] investment options have been
selected.
o No additional Premium Payments will be accepted to the contract while the
rider is in force.
o Dollar Cost Averaging is NOT available.
<TABLE>
<CAPTION>
CAPITAL PRESERVATION AGGRESSIVE GROWTH
<S> <C>
% Guardian Cash Fund % Guardian Small Cap Stock Fund
------ ------
10 % TOTAL FOR CLASS (MUST EQUAL 10%) % AIM V.I. Aggressive Growth Fund
------ ------
% Baillie Gifford Emerging Markets Fund
------
GROWTH % Janus Aggressive Growth Portfolio
------
% Guardian Stock Fund % Janus Capital Appreciation Portfolio
------ ------
% Guardian VC 500 Index Fund % Janus Worldwide Growth Portfolio
------ ------
% Guardian VC Asset Allocation Fund % MFS Capital Opportunities Series
------ ------
% Guardian VC High Yield Bond Fund % MFS Emerging Growth Series
------ ------
% Baillie Gifford International Fund % MFS New Discovery Series
------ ------
% AIM V.I. Value Fund 10 % TOTAL FOR CLASS (MUST EQUAL 10%)
------ ------
% AIM V.I. Growth Fund
------
% Fidelity Balanced Portfolio
------
% Fidelity VIP II Contrafund Portfolio
------
% Fidelity VIP Equity-Income Portfolio
------
% Fidelity VIP III Growth Portfolio
------
% Janus Flexible Income Portfolio
------
% Janus Growth & Income Portfolio
------
% MFS Global Government Series
------
% MFS Growth With Income Series
------
% Value Line Centurion Fund
------
% Value Line Strategic Asset Management Trust
------
40 % TOTAL FOR CLASS (MUST EQUAL 40%)
------
INCOME
% Guardian Bond Fund
------
% AIM V.I. Government Securities Fund
------
40 % TOTAL FOR CLASS (MUST EQUAL 40%)
------
</TABLE>
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13. SIGNATURES
As owner of this annuity, I agree the following: (1) To the best of my
knowledge and belief, all statements in this application are complete and
true and were correctly recorded; (2) I am not subject to backup withholding;
(3) My correct Social Security or Taxpayer ID# is given above; (4) I AM IN
RECEIPT OF THE CURRENT PROSPECTUSES FOR THIS ANNUITY CONTRACT AND ITS
UNDERLYING MUTUAL FUNDS; (5) I UNDERSTAND THAT THE VALUE OF THIS ANNUITY
CONTRACT WHICH IS ALLOCATED TO VARIABLE INVESTMENT OPTIONS MAY INCREASE OR
DECREASE AND THE VALUE OF THIS ANNUITY CONTRACT MAY BE MORE OR LESS THAN THE
TOTAL PURCHASE PAYMENTS AT ANY GIVEN POINT IN TIME; (6) I understand that the
contract applied for will not begin until the later of: (a) contract issue,
or (b) GIAC's receipt of the first contract premium; (7) I understand that no
Registered Representative can make or change a contract or waive any of
GIAC's rights or requirements; (8) I understand that GIAC has the unilateral
right to determine if any contract can be issued and to waive or modify any
GIAC requirements; and (9) I understand that there are certain distribution
restrictions under Internal Revenue Code Section 403(b) if this contract is
being purchased in connection with a tax-sheltered annuity plan.
FOR RESIDENTS OF ARIZONA: Upon the owner's written request, GIAC will provide
reasonable factual information regarding the benefits and provisions of the
annuity contract applied for within a reasonable amount of time. If for any
reason the owner is not satisfied with any contract issued in connection with
this application, the owner may return such contract to GIAC's Customer
Service Office or to the agent from whom it was purchased within 10 days
after receiving it. GIAC will pay to the owner an amount equal to the sum of:
1) the difference between any premium(s) paid, including any contract fee or
contingent deferred sales charge, and the amounts allocated to the contract's
Allocation Options; and 2) the Contract's Accumulation Value on the date GIAC
or its agent receives the returned contract.
FOR RESIDENTS OF ARKANSAS, KENTUCKY, LOUISIANA, NEW MEXICO, OHIO AND
PENNSYLVANIA: Any person who knowingly and with intent to defraud any
insurance company or other person files an application for insurance or
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 and subjects
such person to criminal and civil penalties.
FOR RESIDENTS OF 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 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.
FOR RESIDENTS OF FLORIDA: Any person who knowingly and with intent to injure,
defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a
felony of the third degree.
FOR RESIDENTS OF MAINE, WASHINGTON D.C. AND VIRGINIA: It is a crime to
knowingly provide false, incomplete or misleading information to any
insurance company for the purpose of defrauding the company. Penalties may
include imprisonment, fines or a denial of insurance benefits.
__________________________________ _________________________________________
SIGNATURE OF OWNER SIGNATURE OF JOINT OWNER (IF ANY)
_____________________ _____ ____ _________________________________________
SIGNED AT CITY STATE DATE SIGNATURE OF REGISTERED REPRESENTATIVE
_________________________________________
STATE LICENSE # (FOR FLORIDA AGENTS ONLY)
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Broker/Dealer Use Only
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As Registered Representative, I certify witnessing the signature(s) above and
that the answer to the question below is true to the best of my knowledge and
belief.
Does this contract replace any existing annuity contract or life insurance
policy? |_| Yes |_| No
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Suitability Profile:Required for Guardian Agents
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___________________________________________________ ___________________________
APPLICANT'S EMPLOYER APPLICANT'S OCCUPATION
________________________________________________________________________________
BUSINESS ADDRESS OF APPLICANT'S EMPLOYER
__________________________________ _______________________ __________________
CITY STATE ZIP
Were the terms and conditions of this contract thoroughly explained to the
applicant? |_| Yes |_| No
Is the applicant associated with or employed by an NASD member? |_| Yes |_| No
Investment Objective(s) |_| Safety of Principal |_| Income
|_| Growth (long-term capital appreciation)
|_| Diversification |_| Aggressive Growth
|_| Other ____________________________________
Estimated Annual Income (all sources): $________________________________________
Estimated Net Worth (exclusive of family residence): $________________________
Liquid Net Worth: $_____________________________________________________________
Estimated Federal Tax Bracket: _____________________%
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BROKER/DEALER SALES GUARDIAN SALES
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________________________________________ ____________________________________
SIGNATURE OF REGISTERED SIGNATURE OF REGISTERED
REPRESENTATIVE REPRESENTATIVE
________________________________________ ____________________________________
PRINT NAME OF REGISTERED PRINT NAME OF REGISTERED
REPRESENTATIVE REPRESENTATIVE
________________________________________ ____________________________________
PRINT NAME OF CO-REGISTERED PRINT NAME OF CO-REGISTERED
REPRESENTATIVE (IF ANY) REPRESENTATIVE (IF ANY)
________________________________________ ____________________________________
PRINT NAME OF BROKER/DEALER PRINT GUARDIAN AGENCY NAME
________________________________________ ____________________________________
DEALER BRANCH OFFICE STREET ADDRESS GIAC AGENCY CODE
________________________________________ ____________________________________
BRANCH OFFICE CITY STATE ZIP TEL. FAX
________________________________________ ____________________________________
TEL. FAX R.R./CO-R.R. CODE E-MAIL
________________________________________
BRANCH NO./R.R. NO. E-MAIL
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This space for use of GIAC
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C-Share Application Back Cover
