EX-4.D 2 v70454paex4-d.txt EXHIBIT 4.D 1
Exhibit 4(d) 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 Lock Box 100330 [LOGO] ANCHOR NATIONAL WM without checks: Pasadena, CA 91105 A SUNAMERICA COMPANY DIVERSIFIED STRATEGIES P.O. Box 54299 ----------------------------- Los Angeles, CA 90054-0299 COMMON SENSE. UNCOMMON SOLUTIONS. ------------------------------------------------------------------------------------------------------------------------------------ DEFERRED ANNUITY APPLICATION ANA-505OR (3/01) DO NOT USE HIGHLIGHTER. Please print or type. [A] OWNER ==================================================================================================================================== ------------------------------------------------------------------------------------------------------------------------------------ LAST NAME FIRST NAME MIDDLE INITIAL ------------------------------------------------------------------------------------------------------------------------------------ STREET ADDRESS ------------------------------------------------------------------------------------------------------------------------------------ CITY STATE ZIP CODE MO. DAY YR. [ ]M [ ]F ( ) ------------------------------ --------------- ------------------------------ ---------------- DATE OF BIRTH SEX SOC. SEC. OR TAX ID NUMBER TELEPHONE NUMBER ----------------------------------------------------------------------------------------------------------------------------------- JOINT OWNER (If applicable) LAST NAME FIRST NAME MIDDLE INITIAL MO. DAY YR. [ ]M [ ]F ( ) ------------------------------ --------------- ------------------------------------------------- ---------------- DATE OF BIRTH SEX SOC. SEC. OR TAX ID NUMBER RELATIONSHIP TO OWNER TELEPHONE NUMBER [B] ANNUITANT (Complete only if different from Owner) ==================================================================================================================================== ----------------------------------------------------------------------------------------------------------------------------------- LAST NAME FIRST NAME MIDDLE INITIAL ----------------------------------------------------------------------------------------------------------------------------------- STREET ADDRESS ----------------------------------------------------------------------------------------------------------------------------------- CITY STATE ZIP CODE MO. DAY YR. [ ]M [ ]F ( ) ------------------------------ --------------- ------------------------------ ---------------- DATE OF BIRTH SEX SOC. SEC. OR TAX ID NUMBER TELEPHONE NUMBER ----------------------------------------------------------------------------------------------------------------------------------- JOINT ANNUITANT (If applicable) LAST NAME FIRST NAME MIDDLE INITIAL MO. DAY YR. [ ]M [ ]F ( ) ------------------------------ --------------- ------------------------------------------------- ---------------- DATE OF BIRTH SEX SOC. SEC. OR TAX ID NUMBER TELEPHONE NUMBER RELATIONSHIP TO OWNER [C] BENEFICIARY (Please list additional beneficiaries, if any, in the special instructions section.) =================================================================================================================================== (*) IMPORTANT NOTE TO JOINT OWNERS: THE DEATH OF ANY JOINT OWNER TRIGGERS A BENEFIT PAYABLE TO THE BENEFICIARY DESIGNATED BELOW. IF YOU WISH THE SURVIVING JOINT OWNER TO RECEIVE THE BENEFIT YOU MUST DESIGNATE ACCORDINGLY BELOW. --------------------------------------------------------------------------------------------- [X] 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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----------------------------------------------------------------------------------------------------------------------------------- DEFERRED ANNUITY APPLICATION ANA-505OR (3/01) SIDE 2 ----------------------------------------------------------------------------------------------------------------------------------- [D] TYPE OF CONTRACT (If this is a transfer or 1035 Exchange, please complete form (SA-2500RL) and submit it with this application.) ==================================================================================================================================== [ ] NON-QUALIFIED PLAN (Minimum $5,000) [ ] QUALIFIED PLANS (Minimum $2,000) [ ] IRA (tax year) ________________ ) [ ] IRA Transfer [ ] IRA Rollover [ ] Roth IRA [ ] 401(k) [ ] Keogh [ ] SEP [ ] TSA [ ] 457 [ ] Other ______________________ [ ] Check included with this application for $ _______________________________________________ [E] ANNUITY DATE ==================================================================================================================================== Date annuity payments ("income payments") begin. Must be at least 2 years after the Contract Date. Maximum annuitization age is the later of the Owner's age 90 or 10 years after Contract Date. NOTE: If left blank, the Annuity Date will default to the maximum for non-qualified and to 70 1/2 for qualified contracts. Month__________________________________ Day_____________________________________ Year__________________________ [F] SPECIAL FEATURES (Optional) ==================================================================================================================================== [ ] SYSTEMATIC WITHDRAWAL: Include Form Number (SA-5550SW) with this application. [ ] OPTIONAL DEATH BENEFIT ELECTION: Include Form Number (DS-2220POS) with this application. [ ] PRINCIPAL ADVANTAGE: Check the appropriate fixed account below and specify the other allocations as percentages in section I. [ ] 1 Year Fixed [ ] AUTOMATIC ASSET REBALANCING: I request the accounts to be REBALANCED as designated in section I at the frequency initialed below: (Select only one) NA Monthly Quarterly Semi-Annually Annually ------- -------- -------- -------- [G] TELEPHONE 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 transfers. I authorize the Company to accept telephone instructions for transfers in any amount among investment options from anyone providing proper identification. I understand that I bear the risk of loss in the event of a telephone 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. [H] ADDITIONAL INSTRUCTIONS (Additional Beneficiaries, Transfer Company Information, etc.) ==================================================================================================================================== ----------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------
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----------------------------------------------------------------------------------------------------------------------------------- DEFERRED ANNUITY APPLICATION ANA-505OR (3/01) SIDE 3 ----------------------------------------------------------------------------------------------------------------------------------- [I] INVESTMENT & DCA INSTRUCTIONS (Allocations must be expressed in whole percentages and total allocation must equal 100%) ==================================================================================================================================== PAYMENT DCA TARGET FIXED ACCOUNT OPTIONS ALLOCATIONS ALLOCATIONS PORTFOLIO _______% 1 yr. STRATEGIC ASSET MANAGEMENT PORTFOLIOS _______% _______% WM Strategic Growth DCA OPTIONS AND PROGRAM(*) _______% _______% WM Conservative Growth _______% _______% WM Balanced _______% 6 Month DCA Account (Monthly DCA Only) _______% _______% WM Conservative Balanced _______% _______% WM Flexible Income _______% 1 yr. DCA Account Frequency (Select one below) EQUITY FUNDS [ ] Monthly [ ] Quarterly _______% _______% WM Equity Income (*) The DCA Program will begin 30 days (if monthly) or 90 days (if quarterly) from the date of deposit. Please indicate _______% _______% WM Growth & Income the target account(s) in the spaces provided to the left. The total must equal 100%. The minimum transfer amount is $100. We reserve the right to adjust the number of _______% _______% Davis Venture Value transfers in order to meet the minimum transfer amount. _______% _______% WM Growth Fund of the Northwest _______% _______% Alliance Growth _______% _______% WM Growth _______% _______% Capital Appreciation _______% _______% MFS Mid-Cap Growth _______% _______% WM Mid Cap Stock _______% _______% WM Small Cap Stock _______% _______% Global Equities _______% _______% WM International Growth _______% _______% Technology FIXED INCOME FUNDS _______% _______% WM Money Market _______% _______% WM Short Term Income _______% _______% WM U.S. Government Securities _______% _______% WM Income
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----------------------------------------------------------------------------------------------------------------------------------- DEFERRED ANNUITY APPLICATION ANA-505OR (3/01) SIDE 4 ----------------------------------------------------------------------------------------------------------------------------------- [J] STATEMENT OF OWNER ==================================================================================================================================== Will this Contract replace an existing life insurance or annuity contract? [ ] YES [ ] NO (If yes, please attach transfer forms, replacement forms and indicate the name and contract number of the issuing company below.) --------------------------------------------------------------------------------------------------- ------------------------ COMPANY NAME CONTRACT NUMBER 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 Deferred Annuity Application Form shall be a part of any Contract issued by the Company. I VERIFY MY UNDERSTANDING THAT THE VALUE OF PURCHASE PAYMENTS DIRECTED INTO THE VARIABLE INVESTMENT OPTIONS 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, 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 DIVERSIFIED STRATEGIES, INCLUDING THE SUNAMERICA SERIES TRUST, ANCHOR SERIES TRUST AND WM VARIABLE TRUST PROSPECTUSES. I HAVE READ THEM CAREFULLY AND UNDERSTAND THEIR CONTENTS. I FURTHER VERIFY MY UNDERSTANDING THAT THIS VARIABLE ANNUITY IS SUITABLE TO MY OBJECTIVES AND NEEDS. Signed at ---------------------------------------------------------------------------------- ------------------------- CITY STATE DATE ------------------------------------------------- ----------------------------------------------------------------------------- OWNER'S SIGNATURE JOINT OWNER'S SIGNATURE (IF APPLICABLE) ------------------------------------------------- REGISTERED REPRESENTATIVE'S SIGNATURE [K] LICENSED / REGISTERED REPRESENTATIVE INFORMATION ==================================================================================================================================== Will this Contract 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 AGENT'S LICENSE ID NUMBER ----------------------------------------------------------------------------------------------------------------------------------- For Office Use Only Account #: WM Diversified Strategies / Product Code 6 Branch #: Trade #: -----------------------------------------------------------------------------------------------------------------------------------