EX-5 13 dex5.htm SEASONS ADVISORS II APPLICATION Prepared by R.R. Donnelley Financial -- Seasons Advisors II Application
 
EXHIBIT 5
 
Anchor National
  
New Business Documents
  
Overnight With Checks
Life Insurance Company
  
With Checks
  
BONPC
1 SunAmerica Center
  
P.O. Box 100330
  
1111 Arroyo Parkway
Los Angeles, CA 90067-6022
  
Pasadena, CA 91189-0001
  
Suite 150
   
Without Checks
  
Lock Box 10330
   
P.O. Box 54299
  
Pasadena, CA 91105
   
Los Angeles, CA 90054-0299
    
 
[VARIABLE ANNUITY APPLICATION]
   
ANA-562 (3/02)
Please print or type.
 
A.    OWNER/PARTICIPANT
 
                                             
Last Name
                    
First Name
                
Middle Initial
                                         
Street Address
                                        
                                         
City
               
State
                
Zip Code
         
                                             
Mo.
  
Day
  
Year
       
¨ M ¨ F
                
(      )
         
   
   
   
   
Date of Birth
           
Sex
       
SSN or TIN
       
Telephone Number
       
Email Address
                                         
JOINT OWNER/ PARTICIPANT: (If
Applicable)
                
Last Name
                
First Name
       
Middle Initial
                                             
Mo.
  
Day
  
Year
       
¨ M ¨ F
                         
(      )
   
   
   
   
Date of Birth
           
Sex
       
SSN
       
Relationship to Participant
       
Telephone Number
 
B.    ANNUITANT (Complete only if different from Owner/Participant)
 
                                             
Last Name
                    
First Name
                
Middle Initial
                                         
Street Address
                                        
                                         
City
               
State
                
Zip Code
         
                                             
Mo.
  
Day
  
Year
       
¨ M ¨ F
                
(      )
   
   
   
Date of Birth
           
Sex
       
SSN
                
Telephone Number
                                         
JOINT ANNUITANT (If Applicable):
                
Last Name
                
First Name
       
Middle Initial
                                             
Mo.
  
Day
  
Year
       
¨ M ¨ F
                
(      )
   
   
   
Date of Birth
           
Sex
       
SSN
                
Telephone Number
 
C.    OPTIONAL ELECTIONS (See your financial representative and the prospectus for information about optional elections.)
 
OPTIONAL DEATH BENEFIT ELECTIONS: This optional benefit may only be chosen at the time of application. Once any Optional Death Benefit is selected, it replaces the standard death benefit in the Contract and the option cannot be terminated or changed. The Owner/Participant may select one Optional Death Benefit from Section I below. If an Optional Death Benefit is selected from Section I the Owner/Participant may also elect the Optional Death Benefit Enhancement in Section II below.
 
I.
 
¨  Purchase Payment Accumulation                                         ¨  Maximum Anniversary Value 
    
 
The Optional Death Benefits referenced above are available through issue age 80 (See the prospectus for details).
 
II.
 
¨  Earnings Advantage - Optional Death Benefit Enhancement: This feature is offered as an enhancement to the Optional Death Benefit selected above and is not available if the Optional Death Benefit above is not selected. This option is available through issue age 80 (See the prospectus for details).
 
D.    BENEFICIARY (Please list additional beneficiaries, if any, in the special instructions section)
 
þ Primary
                              
 
   
   
   
Last Name
  
First Name
  
M I
       
Relationship
       
Percentage
¨ Primary ¨ Contingent
                              
 
   
   
   
Last Name
  
First Name
  
M I
       
Relationship
       
Percentage
¨ Primary ¨ Contingent
                              
 
   
   
   
Last Name
  
First Name
  
M I
       
Relationship
       
Percentage

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E.    TYPE OF CONTRACT / CERTIFICATE (If this is a transfer or 1035 Exchange, please complete form [SA2500RL(2/01)] and submit it with this Application Form)
 
r QUALIFIED PLAN     MINIMUM [$2,000]
   
PLEASE INDICATE SPECIFIC QUALIFIED PLAN TYPE BELOW:
¨ IRA (tax year ________)
        
¨ IRA TRANSFER
   
¨ IRA ROLLOVER
        
¨ ROTH IRA
¨ 401(K)
   
¨ 457
   
¨ KEOGH
   
¨ SEP
   
¨ TSA
   
¨ OTHER ___
r NON-QUALIFIED PLAN     MINIMUM [$10,000]
               
¨ Check included with this Application form for $_______________________
          
 
F.    SPECIFIED ANNUITY DATE: Date annuity payments (“income payments”) begin. (Must be at least 2 years after the Contract/Certificate Date. Maximum annuitization age is the later of the Participant’s 95th birthday or 10 years after Contract/Certificate Date. Note: If left blank, the Annuity Date will default to the maximum for nonqualified and to 70 ½ for qualified Certificates.)
 
Month                         Day                         Year
 
G.    SPECIAL FEATURES (Optional)
 
¨
 
SYSTEMATIC WITHDRAWAL: Include Form Number [SA-5550SW (8/00)] with this Participant Enrollment Form.
¨
 
AUTOMATIC ASSET REBALANCING: I request the accounts to be REBALANCED as designated in section K at the frequency initialed below:
    
 
(Select only one)    __________ Quarterly    __________ Semiannually    __________ Annually
 
H.    TELEPHONE / INTERNET TRANSFERS AUTHORIZATION
 
I ¨ DO ¨ DO NOT authorize telephone transfers, subject to the conditions set forth below. If no election is made, the Company will assume that you do authorize telephone or internet transfers. (North Dakota: If no election is made, the Company will assume you do NOT wish to authorize telephone transfers)
 
I ¨ DO ¨ DO NOT authorize Internet transfers, subject to the conditions set forth below?
 
I authorize the Company to accept telephone and/or Internet instructions for transfers in any amount among investment options from anyone providing proper identification subject to restrictions and limitations contained in the Contract/Certificate and related prospectus, if any. I understand that I bear the risk of loss in the event of a telephone or Internet instruction not authorized by me. The Company will not be responsible for any losses resulting from unauthorized transactions if it follows reasonable procedures designed to verify the identity of the requestor and therefore, the Company will record telephone conversations containing transaction instructions, request personal identification information before acting upon telephone instructions and send written confirmation statements of transactions to the address of record. For Internet transfers the Company will require proper password or Internet authentication, keep records of all such transactions and send confirmations to the address of record.
 
Do you authorize the delivery of the prospectus and other required documentation to your personal Internet Address in lieu of receipt by mail?
¨ YES ¨ NO If Yes, You must indicate Your Email Address in the space provided on page 1.
 
I.    ADDITIONAL INSTRUCTIONS ( Additional Beneficiaries, Transfer Company Information; etc.)
 
 
J.    DISCLOSURE NOTICES
 
The following Fraud Warning applies except in Virginia and the states noted below:
 
Fraud Warning: Any Person who with intent to defraud or knowing that he 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 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 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 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 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

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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.
 
For Applicants in Florida: Fraud Warning: 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.
 
For Applicants in Texas: Fraud Warning: Any Person who with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of fraud.
 
For Applicants in Maine: 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 and subjects such person to criminal and civil penalties.
 
For Applicants in Arizona: Upon your written request, we will provide you within a reasonable period of time, reasonable, factual information regarding the benefits and provisions of the 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 after you receive it. If the contract you are applying for is a variable annuity, 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.
 
K.    INVESTMENT & DCA INSTRUCTIONS (Allocations must be expressed in whole percentages and total allocation must equal 100%)
 
Payment Allocations
   
DCA Target Allocations
   
Portfolio
Portfolios
          
________%
   
________%
   
Large Cap Growth Portfolio
________%
   
________%
   
Large Cap Composite Portfolio
________%
   
________%
   
Large Cap Value Portfolio
________%
   
________%
   
Mid Cap Growth Portfolio
________%
   
________%
   
Mid Cap Value Portfolio
________%
   
________%
   
Small Cap Portfolio
________%
   
________%
   
International Equity Portfolio
________%
   
________%
   
Diversified Fixed Income Portfolio
________%
   
________%
   
Cash Management Portfolio
Strategic Asset Management
________%
   
________%
   
Strategic Growth Portfolio
________%
   
________%
   
Conservative Growth Portfolio
________%
   
________%
   
Balanced Portfolio
________%
   
________%
   
Conservative Balanced Portfolio
________%
   
________%
   
Flexible Income Portfolio
Fixed Income Fund
________%
   
________%
   
Short Term Income Fund
________%
   
________%
   
Government Securities Fund
________%
   
________%
   
Income Fund
________%
   
________%
   
Money Market Fund
 
Payment Allocations
   
DCA Target Allocations
   
Portfolio
Strategies
          
________%
   
________%
   
Growth Strategy
________%
   
________%
   
Moderate Growth Strategy
________%
   
________%
   
Balanced Growth Strategy
________%
   
________%
   
Conservative Growth Strategy
Focused Portfolios
________%
   
________%
   
Focus Growth Portfolio
________%
   
________%
   
Focus Growth & Income Portfolio
________%
   
________%
   
Focus TechNet Portfolio
________%
   
________%
   
Focus Value Portfolio
Equity Funds
________%
   
________%
   
Equity Income Fund
________%
   
________%
   
Growth & Income Fund
________%
   
________%
   
Growth Fund of the Northwest
________%
   
________%
   
Growth Fund
________%
   
________%
   
Mid Cap Stock Fund
________%
   
________%
   
Small Cap Stock Fund
________%
   
________%
   
International Growth Fund
 
DCA Fixed Options and Program*
 
________%    6 Month DCA Account
 
________%    1 yr. DCA Account
 
* DCA Program will begin 30 days from the date of deposit. Please indicate the variable investment target account(s) in the spaces provided. Total must equal 100%. The total minimum transfer amount is $100. We reserve the right to adjust the number of transfers in order to meet the minimum transfer amount.
 
ASSET ALLOCATION MODELS
 
Allocate ________% to:
 
¨ Model A         ¨ Model B         ¨ Model C         ¨ Model D         ¨ Model E

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L.    STATEMENT OF PARTICIPANT
 
Do you have any existing life insurance or annuity contracts? ___Yes ___No If yes, will this Contract/Certificate replace an existing life insurance or annuity contract? r Yes r No (If yes, please attach transfer forms, replacement forms and indicate below, the name of the existing issuing company and the contract number.)
 
                 
$
   
   
Company Name
       
Contract Number
       
Estimated Transfer Amount
 
I hereby represent my answers to the above questions to be correct and true to the best of my knowledge and belief and agree that this Application Form shall be a part of any Contract/Certificate issued by the Company. I verify my understanding that all Purchase Payments and values provided by the Contract/Certificate, when based on investment experience of the Subaccounts, are variable and not guaranteed as to dollar amount. If the return of Purchase Payments is required under the Right to Examine Provision of the Contract/Certificate, I understand that the Company reserves the right to allocate my Purchase Payment(s) to the Cash Management Portfolio until the end of the Right to Examine period. I further understand that at the end of the Right to Examine period, the Company will allocate my funds according to my investment instructions. I acknowledge receipt of the current prospectuses for Variable Annuity the [SunAmerica Series Trust and Anchor Series Trust] prospectuses. I have read them carefully and understand their contents. After consulting with my registered representative, I confirm that this variable annuity is suitable to my objectives and needs.
 
Signed at
            
 
   
   
City
  
State
      
Date
         
   
Owner’s/Participant’s Signature
      
Joint Owner/Participant’s Signature (If Applicable)
             
           
Registered Representative’s Signature
            
 
M.    LICENSED / REGISTERED REPRESENTATIVE INFORMATION
 
Will this Contract/Certificate replace in whole or in part any existing life insurance or annuity contract?
¨ Yes    ¨ No
 
          
   
Printed Name of Registered Representative
       
Social Security Number
          
   
Representative’s Street Address
  
City
       
State
       
Zip
        
(      )
                  
   
   
   
Broker/Dealer Firm Name
       
Representative’s Phone Number
       
Licensed Agent ID Number
       
Representative’s Email Address
 
[¨ Option 1    ¨ Option 2    ¨ Option 3    ¨ Option 4    (Check your home office for availability)]
 
For Office Use Only
 

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