EX-5.30 33 ael92297-273973_rvsl.txt FORM OF VARIABLE ANNUITY APPLICATION - ENDEAVOR SELECT ET AL - RVSL 829 Ameriprise Financial Center, Minneapolis, MN 55474 RIVERSOURCE [LOGO](SM) Service line: 1-800-333-3437 ANNUITIES RIVERSOURCE ENDEAVOR SELECT(SM) AND RIVERSOURCE ACCESSCHOICE SELECT(SM) VARIABLE ANNUITY APPLICATION RIVERSOURCE LIFE INSURANCE COMPANY ================================================================================================================================== 1. CONTRACT OWNER NAME (First, Middle Initial, Last) SEX [ ] M [ ] F CITIZENSHIP [ ] U.S. [ ] Other (Country) ______________________ _______________________________________________________________ DATE OF BIRTH (MM/DD/YY) ______________________ Age ___________ ADDRESS (Physical address required - no PO Box) SOCIAL SECURITY NUMBER (Tax Identification Number) _______________________________________________________________ _______________________________________________________________ (City, State, ZIP) (SSN/TIN for this contract owner will be used for tax reporting purposes unless otherwise indicated in SECTION 9 Remarks and _______________________________________________________________ Special Instructions.) MAILING ADDRESS IF DIFFERENT FROM PHYSICAL ADDRESS (Optional) HOME TELEPHONE NUMBER _________________________________________ _______________________________________________________________ E-MAIL ADDRESS ________________________________________________ ================================================================================================================================== 1a. JOINT OWNER NAME (First, Middle Initial, Last) SEX [ ] M [ ] F CITIZENSHIP [ ] U.S. [ ] Other (Country) ______________________ _______________________________________________________________ DATE OF BIRTH (MM/DD/YY) ______________________ Age ___________ ADDRESS (Physical address required - no PO Box) SOCIAL SECURITY NUMBER (Tax Identification Number) _______________________________________________________________ _______________________________________________________________ (City, State, ZIP) _______________________________________________________________ RELATIONSHIP TO CONTRACT OWNER _______________________________________________________________ ================================================================================================================================== 2. ANNUITANT NAME (First, Middle Initial, Last) SEX [ ] M [ ] F DATE OF BIRTH (MM/DD/YY) ______________________ Age ___________ _______________________________________________________________ SOCIAL SECURITY NUMBER (Tax Identification Number) ADDRESS (Physical address required - no PO Box) _______________________________________________________________ _______________________________________________________________ (City, State, ZIP) _______________________________________________________________ MAILING ADDRESS IF DIFFERENT FROM PHYSICAL ADDRESS (Optional for Custodial Accounts) _______________________________________________________________ ================================================================================================================================== 2a. JOINT ANNUITANT NAME (First, Middle Initial, Last) SEX [ ] M [ ] F (FOR 1035 EXCHANGE ONLY) DATE OF BIRTH (MM/DD/YY) ______________________ Age ___________ SOCIAL SECURITY NUMBER (Tax Identification Number) _______________________________________________________________ ADDRESS (Physical address required - no PO Box) _______________________________________________________________ _______________________________________________________________ (City, State, ZIP) _______________________________________________________________ ================================================================================================================================== 3. PRIMARY BENEFICIARY (If additional space needed, please provide this information on a separate piece of paper signed and dated by the contract owner.) NAME DATE OF BIRTH RELATIONSHIP TO ANNUITANT SOCIAL SECURITY NUMBER % ______________________________ _________________ _____________________________ __________________________ ________ ______________________________ _________________ _____________________________ __________________________ ________ 3a. CONTINGENT BENEFICIARY (If additional space needed, please provide this information on a separate piece of paper signed and dated by the contract owner.) NAME DATE OF BIRTH RELATIONSHIP TO ANNUITANT SOCIAL SECURITY NUMBER % ______________________________ _________________ _____________________________ __________________________ ________ ______________________________ _________________ _____________________________ __________________________ ________ ================================================================================================================================== 4. TYPE OF ANNUITY (check one) [ ] Non-qualified [ ] Traditional Individual Retirement Annuity (IRA) [ ] SEP-IRA [ ] Roth IRA [ ] TSA Rollover IF IRA (check and complete applicable types) Traditional IRA: Amount $________ for __________ (year) Rollover IRA: Amount $_______________ Traditional IRA: Amount $________ for __________ (year) Trustee to Trustee IRA: Amount $_______________ Roth Contributory: Amount $________ for __________ (year) Roth Conversion IRA: Amount $_______________ Roth Contributory: Amount $________ for __________ (year) SEP-IRA: Amount $________ for __________ (year) NOTE: If purchasing an annuity within a tax-deferred SEP-IRA: Amount $________ for __________ (year) retirement plan (i.e., IRA), SECTION 8 must also be completed.
------------------------------------------------------------------------------ 273956 APPLICATION CONTINUES End/AccCh Select 273973 C (1/07) ============================================================================== 5. PRODUCT CONTRACT/BENEFIT SELECTION CONTRACT | DEATH BENEFIT OPTIONS: YOU MUST SELECT ONE. | OPTIONAL BENEFITS: YOU MAY SELECT ONLY ONE. -------- | --------------------- | ----------------- [ ] Endeavor Select | If you and the annuitant are age 79 or | Portfolio Navigator must be selected in [ ] 5-Year Withdrawal Charge | younger, please make a death benefit | box 6. [ ] 7-Year Withdrawal Charge | selection below. If no selection is made, [ ] AccessChoice Select | the death benefit will default to ROP. | GUARANTEED MINIMUM INCOME BENEFIT RIDER [ ] Contract Option L | [ ] Return of Payment (ROP) | (GMIB) (through age 75): (4-Year Withdrawal Charge) | [ ] Maximum Anniversary Value (MAV) | [ ] Income Assurer Benefit(SM) rider - MAV; OR [ ] Contract Option C | [ ] 5% Accumulation Death Benefit (5%) | [ ] Income Assurer Benefit(SM) rider - 5%; OR (0-Year Withdrawal Charge) | [ ] Enhanced Death Benefit (EDB) | [ ] Income Assurer Benefit(SM) rider - Greater | | of MAV or 5% | OPTIONAL DEATH BENEFITS YOU MAY SELECT ONE. | OR | ----------------------- | GUARANTEED MINIMUM LIFETIME WITHDRAWAL | Through age 75. Not available with 5% or EDB. | BENEFIT RIDER (GMWB) (through age 80): | [ ] Benefit Protector(SM) Death Benefit | [ ] Guarantor Withdrawal Benefit for Rider, OR Life(SM) rider | [ ] Benefit Protector(SM) Plus Death | OR Benefit Rider (Exchange, transfer or | GUARANTEED MINIMUM ACCUMULATION | rollover only) | BENEFIT RIDER (GMAB) | | [ ] Accumulation Protector Benefit(SM) | | rider
============================================================================== 6. PURCHASE PAYMENTS Initial Purchase Payment $____________________ (FOR DCA, SIP, REBALANCING AND INTEREST SWEEP, COMPLETE THE INVESTMENT OPTIONS FORM.) Payment Allocation* [ ] PORTFOLIO NAVIGATOR (PN) ASSET ALLOCATION PROGRAM - if elected, must be 100%, unless the DCA Fixed Account is also elected. Complete the PN questionnaire and enrollment form. FIXED ACCOUNT _____% RVSL One-Year Fixed Account (not available with contract Option C) _____% 6 month DCA Fixed Account _____% 12 month DCA Fixed Account GUARANTEE PERIOD ACCOUNTS (GPAS) ($1,000 minimum per GPA) _____% 1 Year Guarantee Period Account _____% 2 Year Guarantee Period Account _____% 3 Year Guarantee Period Account _____% 4 Year Guarantee Period Account _____% 5 Year Guarantee Period Account _____% 6 Year Guarantee Period Account _____% 7 Year Guarantee Period Account _____% 8 Year Guarantee Period Account _____% 9 Year Guarantee Period Account _____% 10 Year Guarantee Period Account AIM V.I. _____% Basic Value Fund, Series II Shares _____% Capital Development Fund -Series II Shares _____% Mid Cap Core Equity Fund -Series II Shares ALLIANCEBERNSTEIN VPS _____% Growth and Income Portfolio (Class B) _____% International Value Portfolio (Class B) _____% Balanced Shares Portfolio (Class B) AMERICAN CENTURY VP _____% Inflation Protection, Class II _____% Ultra(R), Class II _____% Value, Class II COLUMBIA _____% Columbia Small Cap Value Fund, Variable Series, Class B _____% Columbia High Yield Fund, Variable Series, Class B DREYFUS VIF _____% Appreciation Portfolio, Service Shares _____% International Value Portfolio, Service Shares DREYFUS IP _____% Midcap Stock Portfolio, Service Shares FIDELITY(R) VIP _____% Contrafund(R) Portfolio Service Class 2 _____% Growth Portfolio Service Class 2 _____% Investment Grade Bond Portfolio Service Class 2 _____% Mid Cap Portfolio Service Class 2 _____% Overseas Portfolio Service Class 2 FRANKLIN TEMPLETON VIP TRUST _____% Franklin Income Securities Fund - Class 2 _____% Franklin Rising Dividends Securities Fund - Class 2 _____% Franklin Small-Mid Cap Growth Securities Fund - Class 2 _____% Mutual Shares Securities Fund - Class 2 _____% Templeton Growth Securities Fund - Class 2 _____% Templeton Global Income Securities Fund - Class 2 GOLDMAN SACHS VIT _____% Mid Cap Value Fund MFS(R) _____% New Discovery Series - Service Class _____% Total Return Series - Service Class _____% Utilities Series - Service Class OPPENHEIMER _____% Capital Appreciation Fund/VA, Service Shares _____% Global Securities Fund/VA, Service Shares _____% Main Street Small Cap Fund/VA, Service Shares _____% Strategic Bond Fund/VA, Service Shares PUTNAM VT _____% Health Sciences Fund - Class IB Shares _____% International Equity Fund - Class IB Shares _____% Small Cap Value Fund - Class IB Shares _____% Vista Fund - Class IB Shares RIVERSOURCE(SM) VP _____% Cash Management Fund _____% Diversified Equity Income Fund _____% Global Inflation Protected Securities Fund _____% High Yield Bond Fund _____% Large Cap Equity Fund _____% Mid Cap Growth Fund _____% S & P 500 Fund _____% Small Cap Value Fund VAN KAMPEN LIT _____% Comstock Portfolio Class II Shares VAN KAMPEN UIF _____% U.S. Real Estate Portfolio Class II Shares WANGER _____% International Small Cap _____% US Smaller Companies ------------------------------------------------------------------------------ 100% MUST BE WHOLE NUMBERS AND TOTAL 100% * Must be whole numbers. Your above payment allocation instructions will remain in effect for any future payments you make until you change your instructions. ------------------------------------------------------------------------------ 273956 APPLICATION CONTINUES End/AccCh Select 273973 C (1/07) ============================================================================== 7. TELEPHONE/ELECTRONIC TRANSACTION AUTHORIZATION By checking "Yes," I/we hereby authorize and direct RiverSource Life Insurance Company (RVSL) to accept telephone or electronic transaction instructions from the agent or registered/licensed assistant who can furnish proper identification to make transfers between accounts, change the allocation of future investments, change the contract address of record, request elective step-up on certain optional riders, and/or to request withdrawals to the extent authorized in the prospectus. RVSL will use reasonable procedures to confirm that these instructions are authorized and genuine. RVSL and I/we agree that these transactions will be made in accordance with procedures specified in the current prospectus for my RVSL variable product. This authorization is valid until I/we cancel it in writing. However, RVSL may, without notice, cancel or suspend this authorization or certain transactions at any time. I/We agree to hold harmless and indemnify RVSL and its affiliates, including each of their directors, officers, employees and agents, for any loss, liability or expense arising from such instructions. [ ] Yes ============================================================================== 8. IF THIS ANNUITY CONTRACT WILL BE USED TO FUND A TAX-DEFERRED RETIREMENT PLAN, PLEASE READ AND COMPLETE THE INFORMATION REQUESTED. 1. I understand that I am purchasing an annuity that will be used to fund a retirement plan that is tax-deferred under the Internal Revenue Code. 2. I understand that any tax deferral benefits will be provided by the retirement plan, and that my annuity will not provide any necessary or additional tax deferral benefits. 3. I have received a copy of "Things to Know About Using an Annuity to Fund Your Tax-Deferred Retirement Plan" and understand the contents. 4. I have reviewed the costs of my annuity (including any mortality and expense risk fees, contract administrative charges, rider charges and withdrawal charges) and have decided that the benefits outweigh the costs for the following reasons (check or list all that apply): [ ] Access to multiple investment managers [ ] Ability to transfer among multiple investment options without additional charges [ ] Availability of subaccount transactions without cost [ ] Access to dollar-cost averaging without cost [ ] Access to asset rebalancing without cost [ ] Death benefit guarantees [ ] Access to enhanced death benefits [ ] Access to enhanced living benefits [ ] Availability of withdrawal charge waivers for nursing home confinement, hospitalization and terminal illness [ ] Availability of settlement options for retirement income or to simplify tax qualified required minimum distributions [ ] Guaranteed lifetime income payout rates [ ] Avoiding the cost and delays of probate and estate settlement [ ] Access to a guaranteed interest rate in the fixed accounts [ ] Access to multi-year interest rate guarantees Other (list) ___________________________________________________________ ________________________________________________________________________ ============================================================================== 9. REMARKS AND SPECIAL INSTRUCTIONS (Include special mailing instructions.)_____________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ============================================================================== 10. REPLACEMENT Will the annuity applied for replace any existing insurance or annuity? [ ] Yes [ ] No If YES, provide details - Company, contract number, amount, reason - under SECTION 9 Remarks and Special Instructions. ============================================================================== 11. SOCIAL SECURITY OR TAXPAYER IDENTIFICATION NUMBER CERTIFICATION You certify, under the penalties of perjury as required by Form W-9 of the Internal Revenue Service, that: (1) The number shown on this form is your correct taxpayer identification number (or you are waiting for a number to be issued to you), and (2) You are not subject to backup withholding because: (a) you are exempt from backup withholding, or (b) you have not been notified by the Internal Revenue Service (IRS) that you are subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified you that you are no longer subject to backup withholding, and (3) You are a U.S. person (including a U.S. resident alien). You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. ------------------------------------------------------------------------------ 273956 APPLICATION CONTINUES End/AccCh Select 273973 C (1/07) ============================================================================== 12. I/WE AGREE THAT: 1. All statements and answers given above are true and complete to the best of my/our knowledge and belief. 2. Only an officer of RiverSource Life Insurance Company can modify any annuity contract or waive any requirement in this application. 3. If joint spousal owners are named, ownership will be in joint tenancy with right of survivorship unless prohibited by state of settlement or specified otherwise in SECTION 9 Remarks and Special Instructions. 4. I/WE ACKNOWLEDGE RECEIPT OF THE CURRENT PROSPECTUS FOR THE VARIABLE ANNUITY. 5. Tax law requires that all non-qualified deferred annuity contracts issued by the same company, to the same contract owner, during the same calendar year are to be treated as a single, unified contract. The amount of income included and taxed in a distribution (or a transaction deemed a distribution under tax law) taken from any one of such contracts is determined by summing all such contracts together. 6. I/We acknowledge receipt of the RiverSource Life Insurance Company Privacy Notice. 7. I/We have read and understood the disclosures, if applicable, listed in SECTION 8 above. 8. If this annuity replaces any existing insurance or annuity, I/we acknowledge receipt of the Variable Annuity Replacement Disclosure or equivalent disclosure. 9. I/We acknowledge receipt of the Product Disclosure. 10. I/WE ACKNOWLEDGE READING ANY APPLICABLE STATE INFORMATION IN SECTION 14 BELOW. 11. I/WE UNDERSTAND THAT EARNINGS AND VALUES, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A VARIABLE FUND, PORTFOLIO, ACCOUNT OR SUBACCOUNT, ARE NOT GUARANTEED AND MAY BOTH INCREASE OR DECREASE. ALLOCATIONS AND TRANSFERS TO GUARANTEE PERIOD ACCOUNT(S) ARE SUBJECT TO MARKET VALUE ADJUSTMENTS PRIOR TO THE DATES SPECIFIED IN THE CONTRACT. 12. THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING (SEE SECTION 11). SIGNATURES LOCATION (City/State) ___________________________________________________ DATE ____________________ X________________________________________________________________________ Owner Signature/Trustee or Custodian Signature (If Owner is Trust or Custodial account) X________________________________________________________________________ Joint Owner (if any) Signature X________________________________________________________________________ X______________________________________________________ Annuitant Signature (if other than Owner) Joint Annuitant Signature ================================================================================================================================== 13. AGENT'S REPORT (Type or Print) To the best of my knowledge, this application [ ] DOES [ ] DOES NOT involve replacement of existing life insurance or annuities. Agent's Name__________________________________________ Agent's Social Security Number ___________________________________________ Agency Name and Number (If applicable) ___________________________________________________________________________________________ Telephone Number __________________________ Fax Number __________________________ Sale Location _________________________________ E-mail Address ________________________________________ Branch Address __________________________________________________________ FOR SPLIT COMMISSIONS, AGENT PERCENTAGE OF COMMISSIONS __________ (IF BLANK, COMMISSIONS WILL BE SPLIT EQUALLY) I hereby certify I personally solicited this application and that the application and this report are complete and accurate to the best of my knowledge and belief. If a replacement is occurring, I have provided details -- company, contract number, amount, reason -- under SECTION 9 Remarks and Special Instructions and have completed any state replacement requirements including any required state replacement forms (and I certify that only insurer approved sales materials were used and copies of all sales material were left with the customer). |----------------------------------| X______________________________________________________________ | FOR AGENT USE ONLY (Check one) | Licensed Agent Signature | [ ] Option A [ ] Option B | | | |----------------------------------| ---------------------------------------------------------------------------------------------------------------------------------- ADDITIONAL AGENT INFORMATION Agent's Name__________________________________________ Agent's Social Security Number __________________________________________ Agency Name and Number (If applicable) ___________________________________________________________________________________________ Telephone Number ___________________________ Fax Number _________________________ Sale Location ________________________________ E-mail Address _________________________________________ Branch Address _________________________________________________________ FOR SPLIT COMMISSIONS, AGENT PERCENTAGE OF COMMISSIONS __________ (IF BLANK, COMMISSIONS WILL BE SPLIT EQUALLY) X______________________________________________________________ Licensed Agent Signature
------------------------------------------------------------------------------ 273956 APPLICATION CONTINUES End/AccCh Select 273973 C (1/07) ============================================================================== 14. STATE SPECIFIC INFORMATION/FRAUD WARNINGS For applicants in Arkansas, Kentucky, Maine, New Mexico, Ohio and -------- -------- ----- --- ------ ---- Pennsylvania: ------------ 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. For applicants in Colorado: -------- ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE OR 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 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 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. AGENT'S PRINTED NAME _____________________________________ AGENT'S FLORIDA LICENSE ID # _____________________________ For applicants in Louisiana: --------- 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 New Jersey: ---------- ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. For applicants in Tennessee: --------- 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. ------------------------------------------------------------------------------ 273956 End/AccCh Select 273973 C (1/07)