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EXHIBIT 5(i)
[ELITEPLUS LOGO] Issued by
American General Annuity
Insurance Company
ELITEPLUS(R) BONUS FIXED
AND VARIABLE ANNUITY
APPLICATION
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AMERICAN AMERICAN GENERAL ANNUITY
GENERAL INSURANCE COMPANY
FINANCIAL GROUP A STOCK COMPANY
205 East 10th Avenue
Amarillo, Texas 79101
800.424.4990
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OWNER (ALL POLICYHOLDER CORRESPONDENCE WILL BE SENT TO THIS ADDRESS.)
Name: Daytime phone: SSN:
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Address: Date of birth: Age:
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Gender: [ ] Male [ ] Female Marital status:
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JOINT OWNER (OPTIONAL. NON-QUALIFIED ANNUITIES ONLY.)
Name: Daytime phone: SSN:
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Date of birth: Age: Gender: [ ] Male [ ] Female Marital status:
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ANNUITANT (IF DIFFERENT FROM THE OWNER, MUST BE AGE 85 OR YOUNGER.)
Name: Daytime phone: SSN:
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Address: Date of birth: Age:
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Gender: [ ] Male [ ] Female Marital status:
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Relationship to Owner:
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OWNER'S BENEFICIARY DESIGNATION(S)
[ ] IF YOU DO NOT WANT THE JOINT OWNER TO BE THE PRIMARY BENEFICIARY, CHECK HERE AND NAME BENEFICIARY BELOW.
PRIMARY BENEFICIARY DESIGNATION(S):
Name: Relationship: SSN: Date of birth:
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Name: Relationship: SSN: Date of birth:
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Name: Relationship: SSN: Date of birth:
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CONTINGENT BENEFICIARY DESIGNATION(S):
Name: Relationship: SSN: Date of birth:
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Name: Relationship: SSN: Date of birth:
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Name: Relationship: SSN: Date of birth:
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ENHANCED DEATH BENEFIT (Optional)
[ ] 3% Rising Floor [ ] Annual Step-Up
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PURCHASE PAYMENT
Initial Purchase Payment: Select Income Date: / /
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Make check payable to: AMERICAN GENERAL ANNUITY Is the Automatic Check Option applicable? [ ] Yes [ ] No
Is this annuity intended to replace or be exchanged for existing life insurance or annuities? [ ] Yes [ ] No
PLAN TYPE (required): [ ]NON-QUALIFIED
TAX-QUALIFIED PLANS: [ ]Traditional IRA [ ]SEP IRA [ ]Roth IRA [ ]401 (Corporate Plan) [ ]403(b) TSA [ ]Other:
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Check one: [ ] Initial Contribution for Tax Year [ ]Transfer [ ]Rollover [ ]Roth IRA Conversion Year
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INVESTMENT ALLOCATION: PLEASE USE ATTACHED INVESTMENT ALLOCATION FORM OR THE PORTFOLIO MODEL FORM FOR PURCHASE PAYMENT ALLOCATION.
A CONTRACT CANNOT BE ISSUED UNLESS THE INVESTMENT ALLOCATION FORM OR THE PORTFOLIO MODEL FORM IS COMPLETED.
American General Annuity Insurance Company is a member of American General Financial Group, the marketing name and service mark
owned and used by American General Corporation and its subsidiaries.
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VA 61-00-A
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AMERICAN AMERICAN GENERAL ANNUITY ELITEPLUS(R) BONUS FIXED AND
GENERAL INSURANCE COMPANY VARIABLE ANNUITY APPLICATION
FINANCIAL GROUP A STOCK COMPANY
205 East 10th Avenue
Amarillo, Texas 79101
800.424.4990
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TELEPHONE TRANSFER AUTHORIZATION
I authorize American General Annuity to act upon transfer instructions given by telephone from _______________________________ (name
of your registered representative/agent) upon furnishing the proper identification. Neither American General Annuity nor any person
authorized by American General Annuity will be responsible for any claim, loss, liability or expense in connection with transfer
instructions received by telephone from such person if American General Annuity or such other person acted on such telephone
instructions in good faith in reliance upon this authorization. American General Annuity will continue to act upon this
authorization until such time as I notify American General Annuity otherwise in writing. ________ (Owner's initials)
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SPECIAL REQUESTS
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SIGNATURES
ACKNOWLEDGMENT: By signing below, the Owner(s) understand(s) that:
o Payments and values when allocated to the Separate Account are variable and are not guaranteed as to dollar amount;
o This annuity is a long-term commitment to meet insurance needs and financial goals; I acknowledge the receipt of the most recent
prospectus for ~the A.G. Annuity Separate Account A and the investment options.
o The variable annuity applied for is not unsuitable for my investment objectives, financial situation and needs; and
o I understand the withdrawal restrictions for 403(b) rollovers under the Internal Revenue Code Section 403(b)(11) on Contributions
and Earnings and have received a prospectus explaining the restrictions. I understand the other investment alternatives available
under the Employer's 403(b) arrangement to which I may elect to transfer my contract value.
NOTICE: The Owner(s) agree(s) that to the best of his/her/their 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 American General Annuity's rights or requirements.
I (we) have read and understand the Acknowledgment and Notice as well as the important disclosure information located on the reverse
side of this application.
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Owner's Signature Joint Owner's Signature (if applicable)
Signed at (city/state): on (date):
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REPRESENTATIVE INFORMATION
ACKNOWLEDGMENT: By signing below, the Registered Rep/Agent certifies that:
o The questions contained in this Application were asked of the Owner(s) and the answers duly recorded. This Application is complete
and true to the best of my knowledge and belief;
o I am NASD-registered and state-licensed for variable annuity contracts where this Application is written and delivered;
o To the best of my knowledge and belief, this Application [ ]does [ ]does not involve replacement of existing life insurance or
annuities. If replacement is involved, I have attached a copy of each disclosure statement and a list of companies involved and
indicated cost basis:
pre-TEFRA $ ; post-TEFRA $ ; and
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o I received $ as the Purchase Payment.
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Registered Rep/Agent's Signature Broker-Dealer Name
State Lic.#: Agent #:
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Registered Rep/Agent (Print name)
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For payments by wire, mail Application to: For payments by check, send application by overnight mail to:
[ ]American General Annuity Insurance Company American General Annuity, Variable Products o
800.424.4990 [ ]205 East 10th Avenue o Amarillo, Texas 79101 800.424.4990 State Street Bank o 1776 Heritage Drive o
N. Quincy, MA 02171 o Attn: Lock Box A3W
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VA 61-00-A
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DISCLOSURES
For Arizona Residents Only: Upon written request, we will provide you with factual information regarding the benefits and provisions
of the annuity contract for which you are applying. If you are not satisfied with your annuity contract for any reason, you may
return it within 20 days after receipt for a refund of premium (applicable to all individual and some group contracts).
REDEMPTIONS FROM OPTIONAL RETIREMENT PROGRAMS AND OTHER PLANS: Distributions from Employer-sponsored retirement programs, including
Optional Retirement Programs, will be subject to any limitations imposed by the plan.
FOR LOUISIANA OPTIONAL RETIREMENT PROGRAM PARTICIPANTS ONLY: For participants in the Louisiana Optional Retirement Program,
withdrawals are limited by the plan and must take the form of an annuity payable over your lifetime or the joint lifetime of you and
your beneficiary.
FOR TEXAS OPTIONAL RETIREMENT PROGRAM PARTICIPANTS ONLY:
o Benefits in the Texas Optional Retirement Program vest after one year and one day of participation in one or more optional
retirement plans.
o Benefits under the Texas Optional Retirement Program are available to you only after you attain the age of 701?2 years, or
terminate participation by death, retirement, or termination of employment in all Texas institutions of higher education.
o AGAIC will require written verification from the program administrator of your qualification for any requested redemption of any
annuity benefits purchased under the Texas Optional Retirement Program.
FRAUD WARNING
IN SOME STATES WE ARE REQUIRED TO ADVISE YOU OF THE FOLLOWING: Any person who knowingly intends to defraud or facilitates a fraud
against an insurer by submitting an application or filing a false claim, or makes an incomplete or deceptive statement of a material
fact, may be guilty of insurance fraud.
ARKANSAS, NORTH DAKOTA, SOUTH DAKOTA, TEXAS, AND WASHINGTON RESIDENTS ONLY: Any person who, with intent to defraud or knowing that
he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive
statement, commits insurance fraud, which may be a crime and may subject the person to civil and criminal penalties.
DISTRICT OF COLUMBIA, COLORADO, KENTUCKY, AND PENNSYLVANIA RESIDENTS ONLY: 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.
FLORIDA RESIDENTS ONLY: 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.
LOUISIANA RESIDENTS ONLY: 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.
NEW JERSEY RESIDENTS ONLY: Any person who includes any false or misleading information on an application for an insurance
policy is subject to criminal and civil penalties.
VIRGINIA RESIDENTS ONLY: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for
the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
VA 61-00-A (10/2000)
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