p0287 Annuity Annotated App Only 090815
How to fill out an Application for BCA Fixed Indexed Annuities Please Note: Please make sure that you are using the most current version of the application. For this either
visit the Athene website or contact your marketer. Athene will accept faxed copies of the application but in most circumstances requires the original transfer paperwork to be submitted.
Agent/Producer Code & Name (Agent/Producer code and name must be listed)
Section 1: Product Product Name - List the name of the annuity product you are applying for. Rider (s) - List the name of the rider(s) you are requesting.
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Section 2: Annuitant (The annuitant must be an individual, Non-person entities are not allowed to be an annuitant)
Name (as to appear on contract) - First, middle initial and Last Name must be listed Gender - Male or Female must be checked Address, City, State, Zip Code & Country - The Annuitant’s full residence address, including street or rural number , city, state, zip and country must be listed. A P.O. Box cannot be used. A P.O. Box may be listed as the mailing address, but only in addition to a physical address.
Social Security Number - Policy cannot be issued without the Annuitant’s Social Security number Date of Birth - The month, day and year must be listed. Each product has a specified maximum issue age. Birth State - Must provide Annuitant’s birth state. Phone Number - Provide Annuitant’s phone number
Section 3: Joint Annuitant
(If applicable)
Name (as to appear on contract) - First, middle initial and Last Name must be listed Gender - Male or Female must be checked Address, City, State, Zip Code & Country - The Joint Annuitant’s full residence address, including street or rural number , city, state, zip and country must be listed
Social Security Number - Policy cannot be issued without the Joint Annuitant’s Social Security Number Date of Birth - The month, day and year must be listed. Each product has a specified maximum issue age. Birth State - Must provide joint annuitant’s birth state. Phone Number - Provide Joint Annuitant’s phone number
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Section 4: Owner (If other than Annuitant) Note: If the Owner is not a natural person, please provide supporting documentation. – IRA, SEP and TSA Name of Individual or Entity (as to appear on contract) - First, middle initial and Last Name must be listed Relationship to the Annuitant - List the Owner’s relationship to the Annuitant Gender - Male or Female must be checked Address, City, State, Zip Code & Country - The Owner’s full residence address, including street or rural number , city, state, zip and country must be listed
Social Security Number or Tax ID Number - Policy cannot be issued without the Owner’s Social Security number or Tax ID number
Date of Birth - The month, day and year must be listed Phone Number - Provide Owner’s phone number
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Section 5: Joint Owner
(Not applicable to qualified contracts)
Name of Individual or Entity - First, middle initial and Last Name must be listed Relationship to the Annuitant - List the Joint Owner’s relationship to the Annuitant Gender - Male or Female must be checked Address, City, State, Zip Code & Country - The Joint Owner’s full residence address, including street or rural number, city, state and zip must be listed
Social Security Number or Tax ID Number - Policy cannot be issued without the Owner’s Social Security number or Tax ID number
Date of Birth - The month, day and year must be listed Phone Number - Provide Joint Owner’s phone number
Section 6: Contingent Owner
(If Owner and Annuitant are different)
Name of Individual or Entity - First, middle initial and Last Name must be listed Relationship to the Annuitant - List the Contingent Owner’s relationship to the Annuitant Gender - Male or Female must be checked Address, City, State, Zip Code & Country - The Contingent Owner’s full residence address, including street or rural number , city, state, zip and country must be listed
Social Security Number or Tax ID Number - Policy cannot be issued without the Contingent Owner’s Social Security number or Tax ID number
Date of Birth - The month, day and year must be listed Phone Number - Provide Contingent Owner’s phone number
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Section 7: Funding Source List premium submitted with the application List premium anticipated from Transfer
Section 8: Tax Qualification (Select ALL that apply) Non-Qualified1 1035 Exchange2 Internal Conversion List contract number
(Typically, both the 1035 Exchange box and the Internal Conversion box are not both checked.)
Qualified (Check the type of
plan you want the funds to be deposited in.)
Check the type of plan the funds are coming from for all Qualified plans. (Check ALL that apply)
IRA
Contribution for Tax Year: _____
Roth IRA
Rollover (Within 60 days)3
SEP IRA
Direct Transfer from IRA/SEP
Keogh/HR-10
Direct Transfer from ROTH IRA
Other Qualified Plan – Owner must be the Plan
ROTH Conversion Direct Transfer from 401(k); HR10; 403(b); Pension Plan
If selecting a Non-Qualified plan, DO NOT make a selection from the middle or right columns. If making a selection from the middle column (Qualified), DO NOT mark anything in the left section (Non-Qualified). 1
Check this box for ALL Non-Qualified plans if this will be a Non-Qualified cash with application or involves a Non-Qualified transfer of funds from a Mutual Fund or Bank CD.
2
Check this box if the Non-Qualified transfer is coming from a Life Insurance policy or a Non-Qualified Annuity only. A Request for Funds form is required.
3
Check this box for third party checks made payable to the Annuitant and endorsed payable to Aviva. Or if the funds were deposited into the Annuitant’s account and a personal check is being sent.
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Section 9: Replacement Answer each question If the first question is answered “Yes”, then a replacement form is required for the following states: AK, AL, AR, AZ, CO, CT, HI, IA, KY, LA, MD, ME, MS, MT, NC, NE, NH, NJ, NM, OH, OR, RI, SC, TX, UT, VA, VT, WI, WV and WY. Also DC, GA, MI and ND do not require replacement forms. If both questions are answered “Yes”, then a product comparison form is required.
Section 10: Beneficiaries (Unless otherwise specified, multiple surviving beneficiaries will share equally. If a
beneficiary is not a natural person, include name and date on the Beneficiary Name line. All beneficiaries must be living at the time of application.)
List each Primary, Contingent or Tertiary Beneficiary and check the appropriate box for each. First and Last Name must be listed Relationship to Annuitant(s) – List the relationship for each Primary beneficiary to the Annuitant(s) Primary, Contigent or Tertiary – Primary, Contingent or Tertiary must be selected Percent – The sum of the percentages for Primary, Contingent and Tertiary beneficiaries , respectively, must total 100%.
Address, City, State, Zip Code & Country - The Beneficiaries’ full residence address, including street or rural number , city, state, zip and country must be listed
Social Security Number or Tax ID number must be listed Date of Birth - The month, day and year must be listed Birth State - The birth state of the beneficiary must be listed Phone Number & Email - Provide beneficiary’s phone number and email Trusts – If the Beneficiary is a trust, indicate the name and date of the trust. Trust verification form must be completed.
Any additional beneficiaries can be listed in the special instructions, Section 11. Or a separate piece of paper with all the required information, signed and dated by the owner.
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Section 11: Special Instructions Use this space for special instructions. Any additional instructions on a separate sheet or attachment must be signed and dated by the Owner.
Section 12: Agreements and Signatures - Failure to obtain all required signatures will result in a delay in getting the policy issued.
City, state and date – Where and when the application was signed. This is not necessarily the state the annuitant
and/or owner resides.
Signatures of the Annuitant, Joint Annuitant (if applicable), Owner (if applicable) and Joint Owner (if applicable) are required
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Section 13: Producer Use Only “Producer Use Only” questions must be answered. They must coincide with the same questions asked of the owner in Section 9.
Signature of Producer, name, producer number, producer phone number and/or email address should be listed. Producer Split – Complete this section for any split producers and indicate the split percentages. Percentages must total 100%.
Option 1 or Option 2 – If unchecked, the default is Option 1.
Option 1: full commission
Option 2: trail commissions
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Additional Forms: Forms can be downloaded from www.athene.com Disclosure Summary - Return the signature page to the home office and leave a copy of the entire Disclosure Statement (pages 1-6) with the applicant. (REQUIRED)
Customer Identification and Suitability Confirmation Worksheet (Form 17341) - MUST BE
COMPLETED IN FULL. Any blank spaces will result in a delay in issuing the policy. If the spouse is listed as a joint owner, only one Suitability Worksheet will be required. If the joint owner is not the spouse, a separate form will need to be completed. (REQUIRED)
Request for Funds form (1035x) - The original form is required and must be completed to transfer funds
from an existing account. The top portion must be complete including: Company name, phone number, address, city, state and zip. Also the Insured/Annuitant/client name, SSN, Owner name & SSN, existing contract/account number, investment vehicle, account type and approximate amount of the transfer must be completed. If the transfer is to take place immediately, the box must be checked. Complete only section 1 or 2. If both sections or the incorrect section is completed, a new original form will be required. If the 1035 transfer is only partial then you will need the specific partial 1035 exchange form, and to verify if partial exchanges are allowed by the clients existing carrier.
Replacement Form (state specific) – If the first question in Section 10 is answered “Yes”, then a replacement form is required for the following states: AK, AL, AR, AZ, CO, CT, HI, IA, KY, LA, MD, ME, MS, MT, NC, NE, NH, NJ, NM, OH, OR, RI, SC, TX, UT, VA, VT, WI, WV and WY. Also DC, GA, MI and ND do not require replacement forms. Two forms are required in IL.
Partial 1035 exchange Request for Funds form - The original form is required and must be completed
to transfer funds from an existing account. The top portion must be complete including: Company name, phone number, address, city, state and zip. Also the Insured/Annuitant/client name, SSN, Owner name & SSN, existing contract/account number, investment vehicle, account type and approximate amount of the transfer must be completed. If the transfer is to take place immediately, the box must be checked.
Product Comparison Worksheet - Required if there is a replacement of an annuity or life insurance (Required for life in AR only)
Optional Forms: IRA Disclosure Statement – must be completed if the plan type selected is an IRA Bonus Election form (varies by product selection and Issue Age) Balanced Allocation Lifetime Income Rider Family Endowment Rider Election Form (varies by product) California Senior Insurance Disclosure Form ROTH IRA Disclosure Statement – must be completed if the plan selected is a Roth IRA Non-Resident Information Sheet – to be used when the signature state is not the
same as the resident state.
Systematic Withdrawal Request form Electronic Funds Transfer form Trust Verification form (must be completed if Trust is the owner and/or beneficiary.) Trust paperwork – if a trust is listed on the application as the owner or beneficiary, a copy of the trust paperwork may be requested.
Florida – Replacement form is state specific Florida also requires an Annuity Product Comparison Form Financial Inventory Worksheet – Required in MN Premium Receipt – Required in AL
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visit the Athene website or contact your marketer. Athene will accept faxed copies of the application but in most circumstances requires the original transfer paperwork to be submitted.
Agent/Producer Code & Name (Agent/Producer code and name must be listed)
Section 1: Product Product Name - List the name of the annuity product you are applying for. Rider (s) - List the name of the rider(s) you are requesting.
2
Section 2: Annuitant (The annuitant must be an individual, Non-person entities are not allowed to be an annuitant)
Name (as to appear on contract) - First, middle initial and Last Name must be listed Gender - Male or Female must be checked Address, City, State, Zip Code & Country - The Annuitant’s full residence address, including street or rural number , city, state, zip and country must be listed. A P.O. Box cannot be used. A P.O. Box may be listed as the mailing address, but only in addition to a physical address.
Social Security Number - Policy cannot be issued without the Annuitant’s Social Security number Date of Birth - The month, day and year must be listed. Each product has a specified maximum issue age. Birth State - Must provide Annuitant’s birth state. Phone Number - Provide Annuitant’s phone number
Section 3: Joint Annuitant
(If applicable)
Name (as to appear on contract) - First, middle initial and Last Name must be listed Gender - Male or Female must be checked Address, City, State, Zip Code & Country - The Joint Annuitant’s full residence address, including street or rural number , city, state, zip and country must be listed
Social Security Number - Policy cannot be issued without the Joint Annuitant’s Social Security Number Date of Birth - The month, day and year must be listed. Each product has a specified maximum issue age. Birth State - Must provide joint annuitant’s birth state. Phone Number - Provide Joint Annuitant’s phone number
3
Section 4: Owner (If other than Annuitant) Note: If the Owner is not a natural person, please provide supporting documentation. – IRA, SEP and TSA Name of Individual or Entity (as to appear on contract) - First, middle initial and Last Name must be listed Relationship to the Annuitant - List the Owner’s relationship to the Annuitant Gender - Male or Female must be checked Address, City, State, Zip Code & Country - The Owner’s full residence address, including street or rural number , city, state, zip and country must be listed
Social Security Number or Tax ID Number - Policy cannot be issued without the Owner’s Social Security number or Tax ID number
Date of Birth - The month, day and year must be listed Phone Number - Provide Owner’s phone number
4
Section 5: Joint Owner
(Not applicable to qualified contracts)
Name of Individual or Entity - First, middle initial and Last Name must be listed Relationship to the Annuitant - List the Joint Owner’s relationship to the Annuitant Gender - Male or Female must be checked Address, City, State, Zip Code & Country - The Joint Owner’s full residence address, including street or rural number, city, state and zip must be listed
Social Security Number or Tax ID Number - Policy cannot be issued without the Owner’s Social Security number or Tax ID number
Date of Birth - The month, day and year must be listed Phone Number - Provide Joint Owner’s phone number
Section 6: Contingent Owner
(If Owner and Annuitant are different)
Name of Individual or Entity - First, middle initial and Last Name must be listed Relationship to the Annuitant - List the Contingent Owner’s relationship to the Annuitant Gender - Male or Female must be checked Address, City, State, Zip Code & Country - The Contingent Owner’s full residence address, including street or rural number , city, state, zip and country must be listed
Social Security Number or Tax ID Number - Policy cannot be issued without the Contingent Owner’s Social Security number or Tax ID number
Date of Birth - The month, day and year must be listed Phone Number - Provide Contingent Owner’s phone number
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Section 7: Funding Source List premium submitted with the application List premium anticipated from Transfer
Section 8: Tax Qualification (Select ALL that apply) Non-Qualified1 1035 Exchange2 Internal Conversion List contract number
(Typically, both the 1035 Exchange box and the Internal Conversion box are not both checked.)
Qualified (Check the type of
plan you want the funds to be deposited in.)
Check the type of plan the funds are coming from for all Qualified plans. (Check ALL that apply)
IRA
Contribution for Tax Year: _____
Roth IRA
Rollover (Within 60 days)3
SEP IRA
Direct Transfer from IRA/SEP
Keogh/HR-10
Direct Transfer from ROTH IRA
Other Qualified Plan – Owner must be the Plan
ROTH Conversion Direct Transfer from 401(k); HR10; 403(b); Pension Plan
If selecting a Non-Qualified plan, DO NOT make a selection from the middle or right columns. If making a selection from the middle column (Qualified), DO NOT mark anything in the left section (Non-Qualified). 1
Check this box for ALL Non-Qualified plans if this will be a Non-Qualified cash with application or involves a Non-Qualified transfer of funds from a Mutual Fund or Bank CD.
2
Check this box if the Non-Qualified transfer is coming from a Life Insurance policy or a Non-Qualified Annuity only. A Request for Funds form is required.
3
Check this box for third party checks made payable to the Annuitant and endorsed payable to Aviva. Or if the funds were deposited into the Annuitant’s account and a personal check is being sent.
6
Section 9: Replacement Answer each question If the first question is answered “Yes”, then a replacement form is required for the following states: AK, AL, AR, AZ, CO, CT, HI, IA, KY, LA, MD, ME, MS, MT, NC, NE, NH, NJ, NM, OH, OR, RI, SC, TX, UT, VA, VT, WI, WV and WY. Also DC, GA, MI and ND do not require replacement forms. If both questions are answered “Yes”, then a product comparison form is required.
Section 10: Beneficiaries (Unless otherwise specified, multiple surviving beneficiaries will share equally. If a
beneficiary is not a natural person, include name and date on the Beneficiary Name line. All beneficiaries must be living at the time of application.)
List each Primary, Contingent or Tertiary Beneficiary and check the appropriate box for each. First and Last Name must be listed Relationship to Annuitant(s) – List the relationship for each Primary beneficiary to the Annuitant(s) Primary, Contigent or Tertiary – Primary, Contingent or Tertiary must be selected Percent – The sum of the percentages for Primary, Contingent and Tertiary beneficiaries , respectively, must total 100%.
Address, City, State, Zip Code & Country - The Beneficiaries’ full residence address, including street or rural number , city, state, zip and country must be listed
Social Security Number or Tax ID number must be listed Date of Birth - The month, day and year must be listed Birth State - The birth state of the beneficiary must be listed Phone Number & Email - Provide beneficiary’s phone number and email Trusts – If the Beneficiary is a trust, indicate the name and date of the trust. Trust verification form must be completed.
Any additional beneficiaries can be listed in the special instructions, Section 11. Or a separate piece of paper with all the required information, signed and dated by the owner.
7
8
Section 11: Special Instructions Use this space for special instructions. Any additional instructions on a separate sheet or attachment must be signed and dated by the Owner.
Section 12: Agreements and Signatures - Failure to obtain all required signatures will result in a delay in getting the policy issued.
City, state and date – Where and when the application was signed. This is not necessarily the state the annuitant
and/or owner resides.
Signatures of the Annuitant, Joint Annuitant (if applicable), Owner (if applicable) and Joint Owner (if applicable) are required
9
Section 13: Producer Use Only “Producer Use Only” questions must be answered. They must coincide with the same questions asked of the owner in Section 9.
Signature of Producer, name, producer number, producer phone number and/or email address should be listed. Producer Split – Complete this section for any split producers and indicate the split percentages. Percentages must total 100%.
Option 1 or Option 2 – If unchecked, the default is Option 1.
Option 1: full commission
Option 2: trail commissions
10
Additional Forms: Forms can be downloaded from www.athene.com Disclosure Summary - Return the signature page to the home office and leave a copy of the entire Disclosure Statement (pages 1-6) with the applicant. (REQUIRED)
Customer Identification and Suitability Confirmation Worksheet (Form 17341) - MUST BE
COMPLETED IN FULL. Any blank spaces will result in a delay in issuing the policy. If the spouse is listed as a joint owner, only one Suitability Worksheet will be required. If the joint owner is not the spouse, a separate form will need to be completed. (REQUIRED)
Request for Funds form (1035x) - The original form is required and must be completed to transfer funds
from an existing account. The top portion must be complete including: Company name, phone number, address, city, state and zip. Also the Insured/Annuitant/client name, SSN, Owner name & SSN, existing contract/account number, investment vehicle, account type and approximate amount of the transfer must be completed. If the transfer is to take place immediately, the box must be checked. Complete only section 1 or 2. If both sections or the incorrect section is completed, a new original form will be required. If the 1035 transfer is only partial then you will need the specific partial 1035 exchange form, and to verify if partial exchanges are allowed by the clients existing carrier.
Replacement Form (state specific) – If the first question in Section 10 is answered “Yes”, then a replacement form is required for the following states: AK, AL, AR, AZ, CO, CT, HI, IA, KY, LA, MD, ME, MS, MT, NC, NE, NH, NJ, NM, OH, OR, RI, SC, TX, UT, VA, VT, WI, WV and WY. Also DC, GA, MI and ND do not require replacement forms. Two forms are required in IL.
Partial 1035 exchange Request for Funds form - The original form is required and must be completed
to transfer funds from an existing account. The top portion must be complete including: Company name, phone number, address, city, state and zip. Also the Insured/Annuitant/client name, SSN, Owner name & SSN, existing contract/account number, investment vehicle, account type and approximate amount of the transfer must be completed. If the transfer is to take place immediately, the box must be checked.
Product Comparison Worksheet - Required if there is a replacement of an annuity or life insurance (Required for life in AR only)
Optional Forms: IRA Disclosure Statement – must be completed if the plan type selected is an IRA Bonus Election form (varies by product selection and Issue Age) Balanced Allocation Lifetime Income Rider Family Endowment Rider Election Form (varies by product) California Senior Insurance Disclosure Form ROTH IRA Disclosure Statement – must be completed if the plan selected is a Roth IRA Non-Resident Information Sheet – to be used when the signature state is not the
same as the resident state.
Systematic Withdrawal Request form Electronic Funds Transfer form Trust Verification form (must be completed if Trust is the owner and/or beneficiary.) Trust paperwork – if a trust is listed on the application as the owner or beneficiary, a copy of the trust paperwork may be requested.
Florida – Replacement form is state specific Florida also requires an Annuity Product Comparison Form Financial Inventory Worksheet – Required in MN Premium Receipt – Required in AL
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