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EXHIBIT 5
[ELITEPLUS VALUE] VARIABLE
ANNUITY APPLICATION
[Home Office Use Only]
[VALIC LOGO] AMERICAN GENERAL ANNUITY
INSURANCE COMPANY
205 East 10th Avenue
Amarillo, Texas 79101
Telephone: 800.424.4990
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<S> <C> <C> <C> <C>
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OWNER Name: Last First Middle Marital Status
(All
Policyholder ------------------------------------------------------------------------------------------------------------------
correspondence Address: Street City State Zip Code
will be sent to
this address.) ------------------------------------------------------------------------------------------------------------------
Date of Birth Age Sex Social Security Number Daytime Telephone:
( )
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JOINT OWNER Name: Last First Middle Marital Status
(Optional,
Non-Qualified ------------------------------------------------------------------------------------------------------------------
Annuities Only.) Date of Birth Age Sex Social Security Number Daytime Telephone:
( )
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ANNUITANT Name: Last First Middle
(If different
from Owner, ------------------------------------------------------------------------------------------------------------------
must be age Address: Street City State Zip Code
85 or younger.
------------------------------------------------------------------------------------------------------------------
Date of Birth Age Sex Social Security Number Relationship to Owner:
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OWNER'S [ ] IF YOU DO NOT WANT JOINT OWNER TO BE THE PRIMARY BENEFICIARY, CHECK HERE AND NAME BENEFICIARY BELOW.
BENEFICIARY ------------------------------------------------------------------------------------------------------------------
DESIGNATION(S) Full Name of Beneficiary(ies) and Relationship to Owner: Relationship: Date of Birth:
(In event of Primary:
Owner's death, ----------------------------------------------------
surviving Joint Social Security Number(s):
Owner becomes
Primary ------------------------------------------------------------------------------------------------------------------
Beneficiary.) Contingent: Relationship: Date of Birth:
----------------------------------------------------
Social Security Number(s):
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PURCHASE Initial Purchase Select Annuity Date Tax-Qualified Plans:
PAYMENT Payment: $ Month Day Year [ ] Traditional IRA [ ] SEP IRA
------------ / 01 / [ ] Roth IRA [ ] 403(b) TSA
Make check payable to: [ ] 401 (Corp. Plan) [ ] Other:
AMERICAN GENERAL ANNUITY If no date is selected, the default date
[ ] Check if Automatic Check is age 85 for Non-Qualified contracts (Circle one): ------------
Option is applicable (age 70 1/2 for Qualified). 1. Transfer 2. Rollover
------------------------------------------------------------------------ 3. Initial Contribution
[ ] Check this box if Contract is Non-Qualified Contribution for Tax Year:
------------------------------------------------------------------------ 19 20
Is this Annuity intended to replace or be exchanged for --------------- ----------------
existing life insurance or annuities [ ] Yes [ ] No Roth Conversion Year
------------------
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INITIAL INVESTMENT ALLOCATION FOR AGA SEPARATE ACCOUNT A
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AGA SEPARATE ACCOUNT A: When a Return of Purchase is required by law during the Right to Examine Contract period, the company will
allocate Purchase Payments to the Money Market Sub-Account as described in the Prospectus. Thereafter, Purchase Payments will be
allocated as directed by the Owner. USE WHOLE PERCENTAGES ONLY. TOTAL MUST EQUAL 100%.
% Oppenheimer Growth and Income Fund % EliteValue Portfolio GENERAL ACCOUNT
----- -----
% Oppenheimer Growth Fund % AIM V.I. Capital Appreciation Fund % 1-year Guarantee Period
----- ----- -----
% Oppenheimer Small Cap Growth Fund % AIM V.I. International Equity Fund % 12-month DCA
----- ----- -----
% Oppenheimer High Income Fund % AIM V.I. Value Fund % 6-month DCA
----- ----- -----
% Oppenheimer Strategic Bond Fund % AIM V.I. Diversified Income Fund
----- -----
% Van Kampen Emerging Growth Portfolio % Templeton Developing Markets Fund - Class 2
----- -----
% Van Kampen Enterprise Portfolio % Templeton International Fund - Class 2
----- -----
% Van Kampen Strategic Stock Portfolio % MFS Emerging Growth Series
----- -----
% Federated American Leaders II % MFS Utilities Series
----- -----
% Federated Fund for U.S. Government Securities II % MFS Research Series
----- -----
% State Street Global Advisors Growth Equity Portfolio % Credit Suisse Growth and Income Portfolio
----- -----
% State Street Global Advisors Money Market Portfolio % Credit Suisse International Equity Portfolio
----- -----
% Salomon Brothers U.S. Government Securities Portfolio
-----
-----% Total
(Must Total 100%)
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DOLLAR COST AVERAGING OPTION: (CHECK EITHER DCA GENERAL ACCOUNT OR MONEY MARKET
SUB-ACCOUNT)
[ ] FROM DCA GENERAL ACCOUNT (MAY ONLY BE SELECTED AT POINT OF APPLICATION)
$________ Amount (Minimum $250) per month). Account balance will be dollar
cost averaged over a (SELECT ONE) [ ] 12-month or [ ] 6-month period from
the Dollar Cost Average General Account to the percentage allocations
indicated below.
[ ] FROM MONEY MARKET SUB-ACCOUNT $_______ Amount (Minimum $250 per month).
Must have a percentage directed to the MONEY MARKET PORTFOLIO in the
initial Investment Allocation above. Dollar Cost Average _____ Monthly
_______ Quarterly ________ Semi-Annually or ________ Annually over a
_______ month period (12-month minimum) from the Money Market Portfolio to
the percentage allocations indicated below.
USE WHOLE PERCENTAGES (WITH A MINIMUM OF 10% PER SUB-ACCOUNT) ONLY. TOTAL MUST
EQUAL 100%.
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_____% Oppenheimer Growth and Income Fund _____% EliteValue Portfolio
_____% Oppenheimer Growth Fund _____% AIM V.I. Capital Appreciation Fund
_____% Oppenheimer Small Cap Growth Fund _____% AIM V.I. International Equity Fund
_____% Oppenheimer High Income Fund _____% AIM V.I. Value Fund
_____% Oppenheimer Strategic Bond Fund _____% AIM V.I. Diversified Income Fund
_____% Van Kampen Emerging Growth Portfolio _____% Templeton Developing Markets Fund - Class 2
_____% Van Kampen Enterprise Portfolio _____% Templeton International Fund - Class 2
_____% Van Kampen Strategic Stock Portfolio _____% MFS Emerging Growth Series
_____% Federated American Leaders II _____% MFS Utilities Series
_____% Federated Fund for U.S. Government Securities II _____% MFS Research Series
_____% State Street Global Advisors Growth Equity Portfolio _____% Credit Suisse Growth and Income Portfolio
_____% State Street Global Advisors Money Market Portfolio* _____% Credit Suisse International Equity Portfolio
_____% Salomon Brothers U.S. Government Securities Portfolio
_____ % Total
(Must Total 100%)
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* (Available only for DCA General Account Option)
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SWEEP ACCOUNT OPTION:
SWEEP THE INCOME ON A _____ MONTHLY _____ QUARTERLY _____ SEMI-ANNUAL OR
_____ ANNUAL BASIS FROM THE GENERAL ACCOUNT TO THE PERCENTAGE ALLOCATIONS
INDICATED BELOW. USE WHOLE PERCENTAGES ONLY. TOTAL MUST EQUAL 100%. GENERAL
ACCOUNT BALANCE MUST BE AT LEAST $25,000.
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<S> <C> <C> <C>
_____% Oppenheimer Growth and Income Fund _____% EliteValue Portfolio
_____% Oppenheimer Growth Fund _____% AIM V.I. Capital Appreciation Fund
_____% Oppenheimer Small Cap Growth Fund _____% AIM V.I. International Equity Fund
_____% Oppenheimer High Income Fund _____% AIM V.I. Value Fund
_____% Oppenheimer Strategic Bond Fund _____% AIM V.I. Diversified Income Fund
_____% Van Kampen Emerging Growth Portfolio _____% Templeton Developing Markets Fund - Class 2
_____% Van Kampen Enterprise Portfolio _____% Templeton International Fund - Class 2
_____% Van Kampen Strategic Stock Portfolio _____% MFS Emerging Growth Series
_____% Federated American Leaders II _____% MFS Utilities Series
_____% Federated Fund for U.S. Government Securities II _____% MFS Research Series
_____% State Street Global Advisors Growth Equity Portfolio _____% Credit Suisse Growth and Income Portfolio
_____% State Street Global Advisors Money Market Portfolio _____% Credit Suisse International Equity Portfolio
_____% Salomon Brothers U.S. Government Securities Portfolio
_____ % Total
(Must Total 100%)
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ASSET ALLOCATION OPTION (PORTFOLIO REBALANCING):
REALLOCATE MY INVESTMENTS _____ MONTHLY _____ QUARTERLY ______ SEMI-ANNUALLY OR
_____ ANNUALLY TO THE PERCENTAGE ALLOCATIONS INDICATED BELOW. USE WHOLE
PERCENTAGES ONLY. TOTAL MUST EQUAL 100%. THE TOTAL VALUE OF THE SUB-ACCOUNTS
MUST BE AT LEAST $25,000.
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<S> <C> <C> <C>
_____% Oppenheimer Growth and Income Fund _____% EliteValue Portfolio
_____% Oppenheimer Growth Fund _____% AIM V.I. Capital Appreciation Fund
_____% Oppenheimer Small Cap Growth Fund _____% AIM V.I. International Equity Fund
_____% Oppenheimer High Income Fund _____% AIM V.I. Value Fund
_____% Oppenheimer Strategic Bond Fund _____% AIM V.I. Diversified Income Fund
_____% Van Kampen Emerging Growth Portfolio _____% Templeton Developing Markets Fund - Class 2
_____% Van Kampen Enterprise Portfolio _____% Templeton International Fund - Class 2
_____% Van Kampen Strategic Stock Portfolio _____% MFS Emerging Growth Series
_____% Federated American Leaders II _____% MFS Utilities Series
_____% Federated Fund for U.S. Government Securities II _____% MFS Research Series
_____% State Street Global Advisors Growth Equity Portfolio _____% Credit Suisse Growth and Income Portfolio
_____% State Street Global Advisors Money Market Portfolio _____% Credit Suisse International Equity Portfolio
_____% Salomon Brothers U.S. Government Securities Portfolio
_____ % Total
(Must Total 100%)
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ACKNOWLEDGEMENT:
BY SIGNING BELOW, THE OWNER(S) UNDERSTAND(S) THAT:
A) PAYMENTS AND VALUES WHEN ALLOCATED TO THE SEPARATE ACCOUNT ARE VARIABLE AND
ARE NOT GUARANTEED AS TO DOLLAR AMOUNT;
B) THIS ANNUITY IS A LONG-TERM COMMITMENT TO MEET INSURANCE NEEDS AND FINANCIAL
GOALS; I (WE) ACKNOWLEDGE RECEIPT OF THE MOST RECENT PROSPECTUS FOR AGA
SEPARATE ACCOUNT A, AGA SERIES TRUST AND ANY APPLICABLE FUND;
C) THE VARIABLE ANNUITY APPLIED FOR IS NOT UNSUITABLE FOR MY (OUR) INVESTMENT
OBJECTIVES, FINANCIAL SITUATION AND NEEDS; AND,
D) FOR 403(b)s, I UNDERSTAND THE WITHDRAWAL RESTRICTIONS UNDER 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.
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NOTICE: (THIS APPLICATION IS SUBJECT TO ACCEPTANCE BY AMERICAN GENERAL ANNUITY
INSURANCE COMPANY.)
The Owner agrees that to the best of his/her 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. If American General
Annuity makes a change in the space designated "Home Office Use Only" in order
to correct any apparent errors or omissions, where allowed by state law, it
will be approved by the acceptance of the Contract; however, any material
changes must be accepted in writing by the Owner.
I HAVE READ AND UNDERSTAND THE ACKNOWLEDGEMENT AND NOTICE.
Signed at on
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City State
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X X X
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Owner Joint Owner (if applicable) Witness and Registered Rep/Agent
-------------------------- ------------------------------- -------------- -----------------
Broker-Dealer Print Name of Registered Rep/Agent State Lic. No. Agent No.
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BY SIGNING ABOVE, THE REGISTERED REP/AGENT CERTIFIES THAT:
A) The questions contained in this Application were asked of the Owner and the
answers duly recorded. This application is complete and true to the best of
my knowledge and belief;
B) I am NASD-registered and state-licensed for variable annuity contracts where
this Application is written and delivered;
C) 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
D) I received $_______________________ as the Purchase Payment.
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FOR American General Annuity Insurance Company FOR American General Annuity Variable Products
PAYMENTS 205 East 10th Avenue APPLICATIONS State Street Bank
BY WIRE, Amarillo, Texas 79101 WITH PAYMENT 1776 Heritage Drive
MAIL (800) 424-4990 BY CHECK, N. Quincy, MA 02171
APPLICATION SEND BY Attn: Lock Box A3W
TO: OVERNIGHT TO: (800) 424-4990
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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 is a crime and may
subject the person to criminal and civil penalties.
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