Deferred Variable Annuity Application
American General Life Insurance Company
Domicile State: Texas
Address mail to:
Annuity Service Center
Regular Mail with checks: P.O. Box 100330
Pasadena, CA 91189-0330
without checks: P.O. Box 15570
Amarillo, TX 79105-5570
Overnight Mail with checks:
2710 Media Center Drive Building #6, Suite 120 Los Angeles, CA 90065-1750
without checks:
1050 North Western Street Amarillo, TX 79106-7011
1-800-445-7862
The indicates a required response. Please print or type.
1 Product Selection (Select one product to ensure Application is processed immediately. Solicitation state indicates the state in which this Application is signed.)
Select one product name (Share Class)
Polaris Platinum III (B) Polaris Choice IV (L)
Solicitation state
(Enter two-character state code)
2 Owner(s) Information
Name Male Female Address City State Zip
Birth Date / / SSN or TIN Phone ( ) Email
Joint Owner (if applicable) Name Male Female Address City State Zip
Birth Date / / SSN or TIN Relationship to Owner Phone ( )
3 Annuitant(s) Information Same as Owner (Complete only if different from Owner)
Name Male Female Address City State Zip
Birth Date / / SSN Phone ( ) Email
Joint Annuitant (if applicable) Name Male Female Address City State Zip
Birth Date / / SSN Phone ( )
ANNUITY PAYMENTS AND VALUES PROVIDED BY THE CONTRACT, WHEN REDEEMED, ARE VARIABLE, ARE NOT GUARANTEED AS TO A FIXED DOLLAR AMOUNT, AND MAY BE WORTH MORE OR LESS THAN THE TOTAL AMOUNT INVESTED.
For applicants in Alaska only: If You are not satisfied with the Contract, You may return it to Our Annuity Service Center or to the agent through whom it was purchased within 10 days (30 days if the Contract replaced any other life insurance or annuity contract(s)) after You receive it. The Company will refund the greater of Purchase Payment(s) paid or the Contract Value on the business day during which the Contract is received. If the Contract replaced any other life insurance or annuity contract(s), the Company will refund the Contract Value on the business day during which the Contract is received. Upon any refund, the Contract shall be void. Upon Your written request, we will provide You with factual information regarding benefits and provisions of the annuity Contract within 10 days.
For applicants in Arizona only: Upon Your written request, we will provide You, within a reasonable period of time, factual information regarding the benefits and provisions of the variable annuity Contract for which You are applying. If for any reason You are not satisfied with the Contract, You may return the Contract within ten days (30 days if You are age 65 or older on the date of the Application or if the Contract replaced any other life insurance or annuity contract(s)) after You receive it. You will receive an amount equal to the sum of (1) the difference between the premiums paid and the amounts allocated to any account under the Contract and (2) the Contract Value on the date the returned Contract is received by Our Company or agent. Upon such refund, the Contract will be void.
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4 Benefi ciary Information
Please complete the beneficiary information below. Additional beneficiaries, if any, can be listed on the Additional Beneficiary Information form (SA2224BNE) and submitted with this Application. Note: If any Living Benefit is elected with Joint Life (2 covered persons) under Section 6(a) below, you must provide the spousal beneficiary information here. (In New Jersey, spouse includes civil union partners.)
If the beneficiary type is not selected, the beneficiary will be designated as “primary.” Multiple beneficiaries will share the death benefit equally unless otherwise specified. For non-individually owned, custodially held IRAs, 457, and qualified plans, if no beneficiary is listed, the beneficiary will default to the Owner listed on this Application.
1. Beneficiary Name Primary Contingent Address
Relationship Beneficiary % SSN/TIN Phone ( )
Birth/Trust Date Email
2. Beneficiary Name Primary Contingent Address
Relationship Beneficiary % SSN/TIN Phone ( )
Birth/Trust Date Email
5 Contract Type (select one) and Source of Funds
Initial Payment: Make check payable to American General Life Insurance Company. If this is a 1035 Exchange, Transfer, or Rollover, please complete the appropriate 1035 Exchange/Transfer form and submit it with this Application. See prospectus for minimum Purchase Payment amounts.
5a. Non-Qualified Contract Or 5b. Qualified Contract
Indicate type and amount of initial payment below. Indicate type of plan for new Contract, source of funds, and amount below.
Amount enclosed: $ Type of Plan for New Contract Source of Funds Amount
1035 Exchange/Transfer IRA 401(a)** Amount enclosed $ Estimated dollars: $ Roth IRA 401(k)** Transfer $ SEP 457 Rollover $ Other Other* Keogh Contribution $ Estimated dollars: $
*(i.e. Bene IRA, PSP, Defined Benefit Plan) IRA Tax Year:
Funds coming direct $
**Is plan subject to ERISA Yes No Funds coming direct $
6 Benefi t Elections
See your registered representative/licensed agent/insurance producer and/or prospectus for information about optional elections, including availability, the maximum issue age, and Investment Requirements.
6(a). Optional Living Benefit Elections: You MUST complete section 6(a) I. I am NOT electing an Optional Living Benefit (proceed to 6(b) below).
II.If electing an Optional Living Benefit, you must check one box under the Living Benefit features section below.
If you elect an Optional Living Benefi t, provide your investment instructions in Section 7(a).
Polaris Income Plus
Option 1 Single Life Up to 6.0% MAWA*
Joint Life** Up to 5.5% MAWA*
Option 2 Single Life Up to 7.0% MAWA*
Joint Life** Up to 6.5% MAWA*
Option 3 Single Life Up to 5.0% for Life
Joint Life** Up to 4.5% for Life
Or
Polaris Income Builder (Minimum Issue Age is 65)
Single Life Up to 5.5% MAWA*
Joint Life** Up to 5.0% MAWA*
*Maximum Annual Withdrawal Amount. Percentage shown is the highest possible. Depending on when you begin withdrawals, the percentage could be lower as shown in the prospectus.
**You must complete the spousal Beneficiary Information in Section 4 for Joint Life Coverage.
6(b). Optional Death Benefit Election: If the Maximum Anniversary Value death benefit is NOT elected, the beneficiary(ies) will receive the Standard death benefit provided in the Contract.
Maximum Anniversary Value (MAV)
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7 Investment Selection / Optional Programs
If you elected Polaris Income Plus or Select your investment options in Section 7(a) and Section 7(b) below.
Polaris Income Builder
If you are not electing a Living Benefit Skip 7(a) and continue with 7(b). Be sure to complete the Investment Option Election Form (IOEF), which must be included with this Application to make specific investment choices.
7(a). Investment Selection for Polaris Income Plus or Polaris Income Builder
Initial Purchase Payment: We automatically allocate 10% of your initial Purchase Payment to the Secure Value Account. You may allocate the remaining 90% to either the “Check-the-Box” option or one or more of the “Individual Portfolios” below. Automatic Asset Rebalancing: As required by the feature named above, if you selected from the “Check-the-Box” option or one or more “Individual Portfolios” below, we rebalance your choice(s) quarterly to the original allocations. We do not include the Secure Value Account in rebalancing.
Dollar Cost Averaging: Invest gradually in your choice(s) below using Dollar Cost Averaging by checking one of the DCA Accounts. Next, choose your Target DCA allocation(s) (options into which fund will gradually be transferred) under either the “Check-the-Box” section or the “Individual Portfolios” section below. DCA Program begins 30 days from the date your initial Purchase Payment is received. 6-Month DCA Account Or 1-Year DCA Account
Check the Box (Select only one of the boxes below)
Select one “Check-the-Box” choice below for your direct investment (not using a DCA Account) or for your Target DCA allocation.
SDAPSDAP (30%) + SDSP (30%) + VCP Managed Asset Allocation (10%) + VCP Total Rtn Bal (10%) + VCP Value (10%) + SVA (10%)SDAP (18%) + SDSP (18%) + VCP Managed Asset Allocation (18%) + VCP Total Rtn Bal (18%) + VCP Value (18%) + SVA (10%)SDAP (30%) + VCP Managed Asset Allocation (20%) + VCP Total Rtn Bal (20%) +VCP Value (20%) + SVA (10%)SunAmerica (45%) + SDSP (45%) + SVA (10%)SunAmerica Dynamic Strategy Portfolio (SDSP) (90%) + SVA (10%) Dynamic Allocation Portfolio (SDAP) (90%) + SVA (10%)
If you elected an Optional Living Benefit in Section 6(a), for this Application to be in good order, you must indicate your investment selection here in the “Check-the-Box” section or choose one or more of the “Individual Portfolios.”
Or
Automatic Secure Value Account Allocation (SVA): 10%
Individual Portfolios (Invest in one or more of the portfolios below)
To invest directly, not utilizing a DCA Account, make your choices in the Payment Allocation column below. To gradually invest using a DCA Account, choose among the funds below using the Target DCA column.
Use whole percentages only.
Payment Allocation Target DCA
Bond Funds (Maximum 90%) complete for direct investment complete if selecting a DCA Account
(invest up to 90% of your initial Purchase Payment in any combination of the following funds; 100% of your Target DCA)
Cash Management (BA) % %
Corporate Bond (Federated) % %
Global Bond (GSAMI) % %
Government and Quality Bond (WMC) % %
Real Return (WMC) % %
SA JPMorgan MFS Core Bond Portfolio % %
SunAmerica Dynamic Portfolios (Maximum 90%)
(invest up to 90% of your initial Purchase Payment in any combination of the following funds; 100% of your Target DCA)
SunAmerica Dynamic Allocation Portfolio % %
SunAmerica Dynamic Strategy Portfolio % %
Single Manager Volatility Control Portfolios (Maximum 90%)
(invest no more than 50% of your initial Purchase Payment in each of the following funds)
VCP Managed Asset Allocation SAST Portfolio (CRMC) % %*
VCP Total Return Balanced (PIMCO) % %*
VCP Value (Invesco) % %*
Total of Individual Funds and/or VCP _ 90 % 100 %
*Allocate no more than 55% of your Target DCA to each of the following funds.
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7 Investment Selection / Optional Programs continued
7(b). Optional Programs
Systematic Withdrawal: Include form SA5550SW with this Application.
Automatic Asset Rebalancing:* I request the investment options referenced in 7(a) above or designated in the Investment Option Election Form to be rebalanced at the frequency selected below.
(Select only one) Quarterly** Semiannually Annually
*Unless separate asset allocation rebalancing instructions are provided and included with this Application, if a DCA Account is elected, we use Target DCA instructions indicated for Automatic Asset Rebalancing instructions.
**If you elected an Optional Living Benefit, Automatic Asset Rebalancing is done quarterly.
7(c). Telephone, Electronic Transaction, and Electronic Delivery Authorization
Yes No Telephone Transaction Authorization Yes No Electronic Transaction Authorization
Your Contract, if issued, will allow for pre-authorized transfer privileges. These privileges allow the Owner, the authorized registered representative/licensed agent/insurance producer of record and any other person(s) authorized by the Owner of the Contract who can furnish proper identification (upon completion by Owner of the authorization below) to make transfers and to change the allocation of future payments.
American General Life Insurance Company (“The Company”) and its affiliates and their directors, trustees, officers, employees, representatives, and/or agents/insurance producers will NOT be liable for complying with transfer instructions it reasonably believes to be authentic, nor for any loss, damage, costs or expenses in acting in accordance with such instructions, and Owner will bear the risk of any such loss (not applicable in Nevada).
The Company will employ reasonable procedures to authenticate that the transfer instructions are genuine and will provide confirmation of all transactions to Owner. If the Company does not employ such procedures, it may be liable for losses due to unauthorized or fraudulent instructions. If no selection is made above, the Company will assume that you authorize telephone transfers and/or electronic requests.
For applicants in California, Florida, Iowa, Nevada, New Hampshire, New Mexico, and North Dakota: If no election is made, the
Company will assume you do NOT want to authorize telephone and/or electronic transfers.
Yes No Electronic Delivery Consent: I consent to electronic delivery by the Company, when available, of:
Legal disclosure materials (prospectuses and prospectus supplements for the variable annuity and the underlying funds and annual and semiannual reports for the underlying funds).
Account documents (quarterly statements and confirmations).
Related correspondence (privacy notice and other notices to customers), as permitted by law.
I confirm that I have access to a computer with the hardware and software necessary (Adobe Acrobat®, Internet access, and an active email account) to receive this information electronically in the form of a compact disc, by email, or by notice to me of a document’s availability on the Company website. I confirm that I have the ability to retrieve and retain electronic communications that are subject to this consent. I understand that I must provide my email address under Section 2 of the Application to use this service.
I understand that:
There is no charge for electronic delivery, although I may incur the costs of Internet access and computer usage. I may always request a paper copy of this information at any time for no charge, even though I consent to electronic delivery. The Company is not required to deliver this information electronically and may discontinue electronic delivery in whole or part at any time.
This consent is effective until further notice by the Company or until I revoke it.
Please call 1-800-445-7862 if you would like to revoke your consent, receive a paper copy of any of the above information via U.S. mail, or need to update your email address indicated in Section 2 of this Application.
8 Notices and Disclaimers
Fraud Warning (applies to all states, except Arizona, Virginia and the states noted below): 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 may be guilty of insurance fraud.
For applicants in Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or who knowingly presents false information in an application for insurance, is guilty of a crime and may be subject to restitution, fines or confinement in prison, or any combination thereof.
For applicants in Arkansas, Rhode Island, and West Virginia: 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.
For applicants in Colorado: Fraud Warning: It is unlawful to knowingly provide false, incomplete, 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 policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Services.
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8 Notices and Disclaimers continued
For applicants in the District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
For applicants in Kentucky: Fraud Warning: Any person, who knowingly and with intent to defraud any insurance company or other person, files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact hereto commits a fraudulent act, which is a crime.
For applicants in Louisiana: WARNING: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
For applicants in Maryland: WARNING: Any person who knowingly OR willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly OR willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
For applicants in Maine, Tennessee, and Washington: Fraud Warning: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits.
For applicants in New Jersey: Fraud Warning: Any person who includes any false information on an application for an insurance policy is subject to criminal and civil penalties.
For applicants in New Mexico: Fraud Warning: 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 civil fines and criminal penalties.
For applicants in Ohio: 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 any false, incomplete, or misleading information is guilty of insurance fraud.
For applicants in Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, makes a claim for the proceeds of an insurance policy containing any false, incomplete, or misleading information is guilty of a felony.
For applicants in Pennsylvania: Fraud Warning: 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.
9 Acknowledgements and Signature(s)
9(a). Replacement
Yes No Do you have any existing life insurance policies or annuity contracts? (Must check either Yes or No.) Yes No Will the purchase of this annuity result in the replacement, termination, or change in value of any existing life insurance policies or annuity contracts? (Must check either Yes or No.)
If yes to either of the above, please provide the information on the required forms, which can be obtained from your registered representative/licensed agent/insurance producer, and include them with this Application.
9(b). California Right-to-Examine Period
For Owners and Annuitants age 60 and older. Under California law, there is a 30-day Right-to-Examine period of your Contract. The amount that will be returned to you if you cancel your Contract during this 30-day period will depend on the election below, which designates where your Purchase Payments will be allocated during the Right-to-Examine period. Please check one of the following boxes. If you do not check one of these boxes, we will automatically invest your funds in the Cash Management investment option for 36 days from the date we issue the Contract. Place my funds into the Cash Management investment option for 36 days from the date the Company issues the Contract, unless I direct otherwise later during the waiting period.
Invest my funds immediately in my chosen stock and/or bond portfolios. I understand that by doing so, I am subjecting my investment to market gain/losses during the waiting period.
9(c). Statement of Owner(s)
I agree that this Application shall be a part of any Contract issued by the Company. Further:
If required in my state*, I have received, read, and understand the Buyer’s Guide for Deferred Annuities.
I acknowledge receipt, either physically or electronically, of the current prospectuses for this variable annuity and the applicable underlying funds of the trusts.
I acknowledge that I have read the current prospectuses for this variable annuity and the applicable underlying funds of the trusts carefully and understand their contents. (Iowa and Minnesota exempted.)
After consulting with my registered representative/licensed agent/insurance producer and reviewing my prospectus, I confirm that this variable annuity and my share class election is suitable for my objectives and needs. I understand that the Company issues other annuities with similar features, benefits, limitations and lower charges. I have discussed the alternatives with my financial representative.
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9 Acknowledgements and Signature(s) continued
I UNDERSTAND THAT ALL PURCHASE PAYMENTS AND VALUES PROVIDED BY THE CONTRACT, WHEN BASED ON INVESTMENT EXPERIENCE OF THE VARIABLE PORTFOLIOS, ARE VARIABLE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT BY THE COMPANY, THE U.S. GOVERNMENT, OR ANY STATE GOVERNMENT; ARE NOT FEDERALLY INSURED BY THE FEDERAL DEPOSIT INSURANCE CORPORATION (FDIC), THE FEDERAL RESERVE BOARD, OR ANY OTHER AGENCY, FEDERAL OR STATE. I BEAR ALL MARKET RISKS, EXCEPT ON AMOUNTS ALLOCATED TO THE AVAILABLE FIXED ACCOUNT OPTIONS.
If I am funding a tax-qualified retirement plan with this annuity, I understand that (1) there are more robust insurance benefits offered in other annuities and (2) the annuity does not provide any additional tax deferral treatment beyond that which I already have under my plan.
I understand that the Company reserves the right to allocate my Purchase Payment(s) and any Initial Payment
Enhancement(s), if applicable, to the cash management investment option until the end of the Right-to-Examine period.
My signature below indicates that I am providing my investment allocation election on the separate Investment Option Election Form, if applicable, included with this Application.
For applicants in Alaska: Information provided by the applicant are representations and not warranties.
For applicants in 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.
My answers are representations and not warranties, and are true and correct to the best of my knowledge and belief.
Owner’s signature Date
Joint Owner’s signature (if applicable) Date
10 Registered Representative / Licensed Agent / Insurance Producer Information and Signature(s)
Yes No Do you have reason to believe that the applicant has any existing life insurance policies or annuity contracts?
Yes No Do you have reason to believe that any existing life insurance policy or annuity contract has been (or will be) replaced, surrendered, withdrawn from, loaned against, changed, or otherwise reduced in value in connection with this transaction assuming that the Contract applied for will be issued?
If yes to either of the above, please provide the information on the required forms, which can be obtained at aig.com/annuities, and include them with this Application.
I affirm that I have instructed the applicant to answer the questions in Section 9(a) appropriately. If the answer to either question is “Yes,” I am providing the information on the required forms and including them with this Application.
If required by the solicitation state*, I have delivered a Buyer’s Guide for Deferred Annuities to the owner.
I am authorized and/or appointed to sell this variable annuity. I have fully discussed and explained the variable annuity features and charges including restrictions to the Owner. I believe this variable annuity is suitable given the Owner’s investment time horizon, goals and objectives, and financial situation and needs. I represent that: (a) I have delivered current applicable prospectuses and any supplements for the variable annuity (which includes summary descriptions of the underlying investment options); and (b) have used only current, approved sales material.
I certify that all information I have taken from the Owner has been truly and accurately recorded on this Application.
1. Registered Representative’s/Licensed Agent’s/Insurance Producer’s signature SSN (1st 5 digits only) - Registered Representative’s/Licensed Agent’s/Insurance Producer’s name (please print)
Address City State Zip Phone ( ) Licensed Agent/Insurance Producer ID number Email Broker/Dealer firm name
If State of Sale is Florida, Florida License ID number
2. Registered Representative’s/Licensed Agent’s/Insurance Producer’s signature SSN (1st 5 digits only) - Registered Representative’s/Licensed Agent’s/Insurance Producer’s name (please print)
Address City State Zip Phone ( ) Licensed Agent/Insurance Producer ID number Email Broker/Dealer firm name
If State of Sale is Florida, Florida License ID number
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10 Registered Representative / Licensed Agent / Insurance Producer Information and Signature(s)
continued
3. Registered Representative’s/Licensed Agent’s/Insurance Producer’s signature SSN (1st 5 digits only) - Registered Representative’s/Licensed Agent’s/Insurance Producer’s name (please print)
Address City State Zip Phone ( ) Licensed Agent/Insurance Producer ID number Email Broker/Dealer firm name
If State of Sale is Florida, Florida License ID number
For Registered Representative/Licensed Agents only. Please contact your home office with any questions. Option 1 Option 2 Option 3 Option 4 Option 5 Option 6
If more than one representative, please indicate applicable percentages (must total 100%):
Representative 1 Representative 2 Representative 3
Note: If there are more than three representatives, please attach all required representative information, including applicable percentages (must total 100%) among all representatives, on a separate document.
*States that require a Buyer’s Guide: AL, CO, GA, IA, OH, RI, TX, WI, WV
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