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Exhibit 99.B5
Application To
AMERICAN NATIONAL INSURANCE COMPANY
One Moody Plaza
Galveston, TX 77550
For
GROUP UNALLOCATED VARIABLE ANNUITY
1. Proposed Contract Owner and Name of Plan
a. Name (s) of Trustee(s) 1. __________________________________________
2. __________________________________________
3. __________________________________________
and (his) (her) (their) successors(s) in trust, as Trustee(s) for
______________________________________________________________________
(print full legal name of Plan and Trust)
b. Trustee's Address: ___________________________________________________
______________________________________________________________________
c. Trust's Tax Identification Number _____ - _______________
2. a. Name of Employer: ___________________________________________________
b. [_] Use Trustee's Address
Employer's Address (if different): ___________________________________
______________________________________________________________________
3. Purchase Payments
a. Initial Purchase Payment $____________
b. Anticipated Lump Sum Purchase Payment $________________
c. Anticipated Annual Purchase Payment $_______________
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4. Allocations of Purchase Payment(s): (Must total 100%)
---------------
<TABLE>
<CAPTION>
AMERICAN NATIONAL FUND ALGER AMERICAN FUND
<S> <C> <C> <C>
Growth Portfolio _____% Small Capitalization Portfolio _____%
Equity Income Portfolio _____% Growth Portfolio _____%
Balanced Portfolio _____% Mid-Cap Growth Portfolio _____%
Money Market Portfolio _____% Leveraged AllCap Portfolio _____%
High Yield Bond Portfolio _____% Income & Growth Portfolio _____%
International Stock Portfolio _____% Balanced Portfolio _____%
Small-Cap/Mid-Cap Portfolio _____% FEDERATED FUND
Government Bond Portfolio _____% Utility Fund II Portfolio _____%
MFS FUND Growth Strategies Portfolio _____%
Capital Opportunities Portfolio _____% International Small Cap Portfolio _____%
Emerging Growth Portfolio _____% High Income Bond Portfolio _____%
Research Portfolio _____% Equity Income Fund II Portfolio _____%
Growth With Income Portfolio _____% FIDELITY FUNDS
T. ROWE PRICE FUNDS Asset Manager Portfolio _____%
Equity Income Portfolio _____% Index 500 Portfolio _____%
Mid-Cap Growth Portfolio _____% Contrafund Portfolio _____%
International Stock Portfolio _____% Asset Manager: Growth Portfolio _____%
Limited-Term Bond Portfolio _____% Growth Opportunities Portfolio _____%
</TABLE>
5. Have you received a Prospectus for the contract applied for? [_] Yes [_] No
6. Telephone Transfer Privilege I (We) hereby authorize and direct American
National Insurance Company to make transfers from fund to fund and/or
change the allocation of future investments based on telephone
instructions. I (We) agree to hold harmless and indemnify American National
Insurance Company, its affiliates and employees and this account for any
claim, loss, liability or expensing arising out of any telephone transfer
effected or any failure or overload of the telephone system.
Initial A or B ONLY if you elect this option.
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[_] A. Telephone Transfer executed by Contract Owner only
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[_] B. Telephone Transfer executed by Contract Owner OR Registered
Representative
I (We) have read the above questions and answers and declare that they are
complete and true to the best of my (our) knowledge and belief. I (We) agree
that this Application shall form a part of any Contract issued and shall
constitute the basis for its issue. I (We) agree that no information acquired
by any registered representative of American National Insurance Company (the
"Company") shall bind the Company unless written on this Application. I (We)
agree that payment of the Initial Purchase Payment will be submitted to the
Company with the Application.
I (We) agree acceptance of the Application on behalf of the Company will only be
effective if:
(i) acceptance is made in writing by an officer of the Company at its Home
Office in Galveston, Texas, and (ii) any check given in payment is paid on
presentment to the bank on which it is drawn. I (We) agree that the Company is
entitled to rely upon the written direction of any one Trustee. The Company is
further entitled to rely upon the continuing authority of each Trustee who has
signed this Application until the Company receives a written notice, sent by
registered or certified mail, certified by the Secretary of the Employer, of a
resolution adopted by such Employer regarding the removal of such Trustee.
Dated at ________________ , ___________ this _____ day of _______________,
_________
Signature of Proposed Contract Owner
Trustee(s):
___________________________________
Trustee
___________________________________
Trustee
___________________________________
Trustee
______________________________________
Signature of Registered Representative
_______________________________ ____________________
Print Registered Representative State License Number
__________________ ___________________________________ ______________________
Broker Dealer Code Registered Representative PC Number Social Security Number
Form 4840
