Valuemark IV
A Flexible Premium Variable Annuity
Issued by Allianz Life Insurance Company of North America DA__________
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1.CONTRACT OWNER Must be age 85 or younger
Name________________________________________________________________
Last First Middle
____________________________________________________________________
(If the Contract Owner is a trust, please include Trust Name, Trust Date,
and the Trust Beneficial Owner(s))
Address_____________________________________________________________
Street Address Apartment Number
____________________________________________________________________
City State Zip Code
Social Security Number__________Date of Birth_____________Sex ____Female
____Male
(If the Contract Owner is a
Daytime Telephone (___)_______trust, list the date(s) of birth
for the Trust Beneficial Owner(s))
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2.JOINT OWNER(Optional)
Must be age 85 or younger. Must be the Spouse of the Contract Owner.
Name_______________________________________________________________
Last First Middle
Social Security Number__________Date of Birth_____________Sex ____Female
____Male
Daytime Telephone (___)____________________
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3.ANNUITANT
Must be age 85 or younger. Must complete if different than Contract owner.
Name _________________________________________________________
Last First Middle
Address ___________________________________________________________
Street Address Apartment Number
____________________________________________________________________
City State Zip Code
Social Security Number________Date of Birth Sex ____Female
____Male
Daytime Telephone________________Relationship to Owner_________________
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4.BENEFICIARY(IES) DESIGNATION
Primary Beneficiary(ies): Contingent Beneficiary(ies)
(At the Contract Owner's death, the surviving Joint Owner becomes the
Primary Beneficiary.)
__________________________________ ______________________________
Name Name
__________________________________ ______________________________
Relationship to Contract Owner Relationship to Contract Owner
__________________________________ ______________________________
Name Name
__________________________________ ______________________________
Relationship to Contract Owner Relationship to Contract Owner
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5. REPLACEMENT
Is this Annuity intended to replace or change existing life insurance or
annuity? ___Yes - Please attach appropriate forms.
___ No
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6. TAX QUALIFIED PLANS
Is this annuity part of a Tax
Qualified Plan? ____ Yes ____No If yes, please select one of the following.
___IRA Transfer/Rollover ___403(b)TSA
___Regular Contribution
for Tax Year________
___Roth IRA ___401 (Corporate Plan)
___Roth IRA Conversion ___Other _______________
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7.PURCHASE PAYMENT Minimum Initial Purchase Payment
____Purchase Payment Enclosed with Application
Purchase Payment Amount $_____________________
____This contract will be funded by a 1035 Exchange, Tax Qualified
Transfer/Rollover, CD or Mutual Fund Redemption. (If checked, please attach
the appropriate forms).
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8.PURCHASE PAYMENT ALLOCATION
You may select up to 10 Investment Options. Use whole percentages. Total must
equal 100%. The allocations you indicate below will become your allocations on
all future payments until you notify us of a change.
_____% AIM V.I.Growth
_____% Alger American Growth
_____% Alger American Leveraged AllCap
_____% Franklin Aggressive Growth Securities
_____% Franklin Global Communications Securities
_____% Franklin Global Health Care Securities
_____% Franklin Growth and Income Securities
_____% Franklin High Income
_____% Franklin Income Securities
_____% Franklin Large Cap Growth Securities
_____% Franklin Money Market
_____% Franklin Natural Resources Securities
_____% Franklin Real Estate
_____% Franklin Rising Dividends Securities
_____% Franklin S&P 500 Index
_____% Franklin Small Cap
_____% Franklin Technology Securities
_____% Franklin U.S. Government
_____% Franklin Value Securities
_____% Franklin Zero Coupon Fund-2000
_____% Franklin Zero Coupon Fund-2005
_____% Franklin Zero Coupon Fund-2010
_____% Mutual Discovery Securities
_____% Mutual Shares Securities
_____% Templeton Asset Strategy
_____% Templeton Developing Markets Securities
_____% Templeton Global Income Securities
_____% Templeton Growth Securities
_____% Templeton International Securities
_____% Templeton International Smaller Companies
_____% Templeton Pacific Growth Securities
_____% USAllianz VIP Diversified Assets
_____% USAllianz VIP Fixed Income
_____% USAllianz VIP Growth
_____% Allianz Life Fixed Account
(Select one of the options below)
__ 6-Month Dollar Cost Averaging
__ 12-Month Dollar Cost Averaging
__ Flexible Fixed Option
_______ TOTAL (Must equal 100%)
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9. Bonus Election (Optional) Must be age 70 or younger to elect the bonus
options.
You can choose the Immediate Bonus Option, Loyalty Bonus Option or
both. There is an additional charge assessed to the Contract Owner for these
options. Check the box(es) below to select one or both of these bonus options.
The Immediate Bonus Option can only be made at the time of initial Purchase
Payment. Refer to the Prospectus for additional information.
____Immediate Bonus Option: Each Purchase Payment made within the first 6 months
of the Issue Date will be credited with a bonus amount of 3.5%. Subsequent
Purchase Payments made after 6 months from the Issue Date will not be
credited with the Immediate Bonus. The bonus will be credited at the time
the Purchase Payment is received. The bonus amounts will be allocated the
same as your Purchase Payments. (In the event of the Contract Owner's
death before the first Contract Anniversary from the Issue Date, we will
take back the bonus before calculating the death benefit. In the event the
Contract is revoked during the Right to Examine period, we will take back
the bonus.) This option can only be made at the time of initial Purchase
Payment. Upon making this selection, it cannot be changed. (The Immediate
Bonus is not available for Contracts owned by a Charitable Remainder
Trust.)
If you do not check the box, you will not receive this benefit.
____ Loyalty Bonus Option: We will credit a bonus amount equal to 3.25% of the
Contract Value on the 7th Contract Anniversary. This bonus will vest 5
years from the date it is credited. During this 5-year period, none of
the bonus will be available for full surrender, partial surrender, or
annuitization. (In the case of a death benefit, the bonus will be fully
vested if death occurs more than 12 completed months after the 7th
Contract Anniversary. In the event of the Contract Owner's death within
the first 12 months from the 7th Contract Anniversary, we will take back
the bonus before calculating the death benefit amount.) This option can
be elected at any time prior to the 7th Contract Anniversary.
If you do not check the box, you will not receive this benefit.
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10. Death Benefit Election (this section must be completed - do not skip this
section)
Valuemark IV offers you a choice between two Enhanced Death Benefit Options
which are applicable to contracts owned for the benefit of an individual. Check
only one box below. If you do not choose one of the options below, your initial
Purchase Payment will not be invested. This selection can only be made at the
time of initial Purchase Payment. Upon making this selection, it cannot be
changed. Refer to the Prospectus for additional information.
___ Option 1: 5% Increase/6-Year Step Up Guarantee: is equal to the greater of:
1) Contract Value; or
2) Purchase Payments less surrenders; or
3) After the first Contract Anniversary, the greater of:
a)5% guaranteed annual increase of Purchase Payments less
surrenders; or
b)The highest 6th year contract anniversary value,
prior to the Contract Owner's 81st birthday, adjusted by
subsequent Purchase Payments less surrenders.
or
___ Option 2: Greatest Anniversary Value Guarantee: is equal to the greater of:
1) Contract Value; or
2) Purchase Payments less surrenders; or
3) Greatest Anniversary Value prior to the Contract Owner's 81st
birthday, adjusted by subsequent Purchase Payments less
surrenders.
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11. Guaranteed Minimum Income Benefit Election (Optional) Must be age 73 or
younger to elect this option.
Valuemark IV offers you a Guaranteed Minimum
Income Benefit* that provides for guaranteed minimum payments. The Guaranteed
Minimum Income Benefit is applicable to contracts owned for the benefit of an
individual. An additional charge is assessed to the Contract Owner for this
benefit. The Guaranteed Minimum Income Benefit will have the same level of
benefits as the Enhanced Death Benefit Option you selected on this application.
Check the box below to select the Guaranteed Minimum Income Benefit. This
selection can only be made at the time of initial Purchase Payment. Upon making
this selection, it cannot be changed. Refer to the Prospectus for additional
information.
___ Guaranteed Minimum Income Benefit (annuitization phase only) if you do not
check the box, you will not receive this benefit.
*Any Annuity Option available under the Contract may be used for this benefit.
However, Annuity Payments can only be made under a Fixed Annuity. The Guaranteed
Minimum Income Benefit is subject to a 7-year waiting period.
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12. INCOME DATE
Selected Income Date ___- 01 -___ The Income Date
(Annuitization Date) may be no earlier than
two years after the Issue Date. The
Guaranteed Minimum Income Benefit does not
take effect until 7 years after the Issue
Date.
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13.TELEPHONE AUTHORIZATION
___ I/We authorize Allianz Life Insurance Company of North America (Allianz
Life) to honor telephone instructions from the Contract Owner(s) to transfer
Contract Values among the variable investment options and the Fixed Account and
to disburse partial surrenders. For partial surrenders, Allianz Life's sole
responsibility is to send a check to the Contract Owner's address or wire the
proceeds to the Contract Owner's account at a commercial bank (a savings bank
may not be used) or to the Contract Owner's account at a member firm of a
national securities exchange.
___ I/We authorize Allianz Life to accept
telephone instructions from the Registered Rep/Agent of Record for this contract
and/or the Representative's Assistant(s) to transfer Contract Values among the
variable investment options and the Fixed Account. If no selection is indicated,
telephone access authorization will be permitted for the Contract Owner only.
This authorization is subject to the terms and provisions in the contract and
Prospectus. Allianz Life will employ reasonable procedures to confirm that
telephone instructions are genuine. If Allianz Life does not, it may be liable
for any losses due to unauthorized or fraudulent transfers.
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14. BY SIGNING BELOW, THE CONTRACT OWNER UNDERSTANDS THAT OR AGREES TO
I received a Prospectus and have determined that the variable annuity applied
for is not unsuitable for my insurance investment objectives, financial
situation, and financial needs. It is a long-term commitment to meet insurance
needs and financial goals. I understand that the annuity value for payments
allocated to the variable investment options may increase or decrease depending
on the contract's investment results, and that no minimum cash value is
guaranteed on the variable investment options. To the best of my knowledge and
belief, all statements and answers in this application are complete and true. It
is further agreed that these statements and answers will become a part of any
contract to be issued. No representative is authorized to modify this agreement
or waive any of Allianz Life's rights or requirements.
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Contract Owner's Signature Joint Owner's Signature (or Trustee,
(or Trustee, if applicable) if applicable)
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Signed At (City, State) Date Signed
____Please send me a Statement of Additional Information
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15.BY SIGNING BELOW, THE REGISTERED REPRESENTATIVE/AGENT CERTIFIES THAT
-I am NASD registered and state licensed for variable annuity contracts in the
state where this application is written and delivered; and
-I provided the Contract Owner(s) with the most current Prospectus; and
-To the best of my knowledge and belief, this application ___DOES___DOES NOT
involve replacement of existing life insurance or annuities. If
replacement, attach a copy of each disclosure statement and list of
companies involved.
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Registered Representative Name (Please Registered Representative Name (Please
Print) Print)
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Registered Representative Signature Registered Representative Signature
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Broker Dealer Name Authorized signature of Broker Dealer
(if required)
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Branch Address Branch Telephone Number
Comm: A B C D(circle one)
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16.MAIL APPLICATIONS TO
For Regular Mail For Overnight Delivery
Allianz Life-USAllianz Service Center Allianz Life-USAllianz Service Center
c/o PNC Bank c/oPNC Bank
Box 824240 Attn: Box 4240
Philadelphia, PA 19182-4240 Route 38 and East Gate Drive
Moorestown, NJ 08057-4240
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17.HOME OFFICE USE ONLY (EXCEPT IN WV)
If Allianz Life Insurance Company of North America makes a change in this space
in order to correct any apparent errors or omissions, it will be approved by
acceptance of this contract by the Owner(s); however, any material change must
be accepted in writing by the Contract Owner(s).
F40112 (5-00)
