Pre-Effective Amendment to Registration Statement for a Separate Account (Unit Investment Trust) — Form N-4
Filing Table of Contents
Document/Exhibit Description Pages Size
1: N-4/A Pre-Effective Amendment to Registration Statement 75 374K
for a Separate Account (Unit Investment
Trust)
2: EX-1 Underwriting Agreement 3 12K
3: EX-3 Articles of Incorporation/Organization or By-Laws 5 17K
4: EX-4 Instrument Defining the Rights of Security Holders 46 217K
5: EX-5 Opinion re: Legality 6± 24K
6: EX-8 Opinion re: Tax Matters 20 56K
7: EX-9 Voting Trust Agreement 2± 10K
8: EX-15 Letter re: Unaudited Interim Financial Information 1 10K
EX-5 — Opinion re: Legality
| EX-5 | 1st “Page” of 2 | TOC | ↑Top | Previous | Next | ↓Bottom | Just 1st |
|---|
CW
U.S.P.S.-First Class American Maturity Life Insurance Company
or Express-Mail to: P.O. Box 5085
Hartford, CT 06102-5085
--------------------------------------------------------------
Private Express Mail: American Maturity Life Insurance Company
200 Hopmeadow Street
Simsbury, CT 06089
REQUEST FOR VARIABLE ANNUITY
American Maturity Life Insurance Company
----------------------------------------------------------------------------
1. CONTRACT OWNER Ownership Type: / / Individual / / Trust / / CRT / / UGMA
/ / UTMA / / NRA / / Corporation / / Other ______________
/ / Mr. / / Mrs. / / Ms. Sex: / / M / / F U.S. Citizen: / / Yes
/ / No
----------------------------------------------------------------------------
First Name MI Last Name
----------------------------------------------------------------------------
Additional Owner Information (e.g., Name of Trust/Corporation)
Email Address
----------------------------------------------------------------------------
Social Security Number/TIN Date of Birth Daytime Telephone Number
----------------------------------------------------------------------------
Street Address City State ZIP
----------------------------------------------------------------------------
2. JOINT CONTRACT OWNER (If any)
/ / Mr. / / Mrs. / / Ms. Sex: / / M / / F U.S. Citizen: / / Yes
/ / No
Date of Birth Social Security Number/TIN
----------------------------------------------------------------------------
First Name MI Last Name
Relationship to Contract Owner
----------------------------------------------------------------------------
3. ANNUITANT (If different from Contract Owner)
/ / Mr. / / Mrs. / / Ms. Sex: / / M / / F
Date of Birth Social Security Number/TIN
----------------------------------------------------------------------------
First Name MI Last Name Daytime Telephone Number
----------------------------------------------------------------------------
Street Address City State ZIP
----------------------------------------------------------------------------
4. CONTINGENT ANNUITANT (If applicable)
/ / Mr. / / Mrs. / / Ms. Sex: / / M / / F
Date of Birth Social Security Number/TIN
----------------------------------------------------------------------------
First Name MI Last Name
----------------------------------------------------------------------------
5. BENEFICIARY(IES) (Unless indicated otherwise, proceeds will be divided
equally. Please attach a separate sheet to add additional beneficiaries.)
----------------------------------------------------------------------------
/ / Primary Relationship to Contract Owner
%
Date of Birth Social Security Number/TIN
----------------------------------------------------------------------------
First Name MI Last Name
----------------------------------------------------------------------------
/ / Primary / / Contingent Relationship to Contract Owner
%
Date of Birth Social Security Number/TIN
----------------------------------------------------------------------------
First Name MI Last Name
----------------------------------------------------------------------------
6. EARNINGS PROTECTION BENEFIT If the Earnings Protection Benefit is
/ / Yes not selected, your beneficiary(ies) will
(.20% charge during the receive the standard death benefit.
accumulation phase.) Please refer to the prospectus for
complete details regarding the death
benefit.
----------------------------------------------------------------------------
7. OPTIONAL DEATH BENEFIT If the Optional Death Benefit is not
/ / Yes selected, your beneficiary(ies) will
(.15% charge during the receive the standard death benefit.
accumulation phase.) Please refer to the prospectus for
complete details regarding the death
benefit.
----------------------------------------------------------------------------
8. PURCHASE PAYMENT (Make check payable to American Maturity Life Insurance
Company)
Monies remitted via: / / Check / / Wire / / 1035(a) Exchange
/ / Transfer/Rollover $ ______________________________________
----------------------------------------------------------------------------
9. PLAN PAYMENT TYPE (Complete Section A or B)
A. NON QUALIFIED / / Initial Purchase / / 1035(a) Tax-Free Exchange
(please provide Cost Basis)
/ / Cost Basis $ ______________________________________
----------------------------------------------------------------------------
B. QUALIFIED / / New Contribution / / Transfer / / Rollover
/ / Contribution for tax year __________________________
----------------------------------------------------------------------------
[Enlarge/Download Table]
INDIVIDUALLY OWNED EMPLOYER PLAN - ALLOCATED
---------------------------------------------------------------------------------------------------------------------------------
/ / Traditional IRA / / Roth IRA / / SEP IRA / / 401(k) / / 401(a) Keogh/HR-10
/ / Custodial / / IRA 403(b) / / SIMPLE IRA (Non-DFI only) / / Other:
----------------------------------------------------------------------------
10. RATE LOCK - 90 DAY FIXED ACCUMULATION FEATURE/DCA PLUS/1035(A)
EXCHANGE/TRANSFER RATE LOCK / / Yes _____%
ESTIMATED DOLLAR AMOUNT $ ___________ IF RATE LOCK IS NOT SELECTED, THE RATE
WILL BE DETERMINED WHEN THE HARTFORD RECEIVES THE FUNDS.
----------------------------------------------------------------------------
----------------------------------------------------------------------------
11. INVESTMENT SELECTION The invested amount will be allocated as selected here.
If choosing an Asset Allocation Program or Dollar Cost Averaging Program,
complete the appropriate enrollment form. PLEASE NOTE: Whole percentages
only.
[Enlarge/Download Table]
% % %
--------------------------------------------------------------------------------------------------------------------------------
Hartford High Yield HLS Fund Fixed Accumulation Feature*
--------------------------------------------------------------------------------------------------------------------------------
Hartford Bond HLS Fund Hartford Index HLS Fund DCA Plus 6-Month Transfer Program*
--------------------------------------------------------------------------------------------------------------------------------
DCA Plus 12-Month Transfer Program*
--------------------------------------------------------------------------------------------------------------------------------
Other
--------------------------------------------------------------------------------------------------------------------------------
Hartford Money Market HLS Fund
--------------------------------------------------------------------------------------------------------------------------------
Hartford Mortgage Securities HLS Fund
--------------------------------------------------------------------------------------------------------------------------------
Total 100%
--------------------------------------------------------------------------------------------------------------------------------
*Subject to state availability.
----------------------------------------------------------------------------
12. SPECIAL REMARKS
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
13. OWNER(S) ACKNOWLEDGEMENTS
Will the annuity applied for replace one or more existing annuity or life
insurance contracts? / / NO / / YES - IF YES, please explain in "Special
Remarks," Section 12.
Have you purchased another deferred annuity issued by The American Maturity
during the current calendar year? / / NO / / YES
----------------------------------------------------------------
NOT FDIC/NCUA INSURED MAY LOSE VALUE NO BANK GUARANTEE
----------------------------------------------------------------
NOT A DEPOSIT NOT INSURED BY ANY FEDERAL GOVERNMENT AGENCY
----------------------------------------------------------------
[Not FDIC Insured Logo] [No Bank Guarantee Logo]
The following states require insurance applicants to acknowledge a fraud
warning statement. Please refer to the fraud warning statement for your
state as indicated below. Check the appropriate box pertaining to your
resident state, sign and date at the bottom of this section.
/ / Arkansas - 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.
/ / 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 (i) the difference between the premiums paid
and the amounts allocated to any account under the contract and (ii) the
Contract Value on the date the returned contract is received by our
company or our agent.
/ / Colorado - 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 a settlement or
award payable from insurance proceeds shall be reported to the Colorado
Division of Insurance within the Department of Regulatory Services.
/ / 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.
/ / Kentucky - 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 thereto commits a
fraudulent act, which is a crime.
/ / Maine - 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.
/ / 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.
/ / New Mexico - 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.
/ / 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 a false or deceptive statement is guilty of
insurance fraud.
/ / 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.
I/we hereby represent my/our answers to the above questions to be true and
correct to the best of my/our knowledge and belief. I/WE UNDERSTAND THAT
ANNUITY PAYMENTS OR SURRENDER VALUES, WHEN BASED UPON THE INVESTMENT
EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND NOT GUARANTEED AS TO A
FIXED DOLLAR AMOUNT.
/ / RECEIPT OF A VARIABLE ANNUITY AND FUND PROSPECTUS IS HEREBY
ACKNOWLEDGED. If not checked, the appropriate prospectus will be mailed
to you.
Signed at: ________________________________ ________ _____/_____/_____
City State Date
___________________________________________________________
Contract Owner Signature (Trustee/Custodian, if applicable)
______________________________________________
Joint Contract Owner Signature (If applicable)
* If the state above is different than residence state,
please submit a Policy Situs Form.
----------------------------------------------------------------------------
14. REGISTERED REPRESENTATIVE ACKNOWLEDGEMENTS
Do you, as agent, have reason to believe ___________________________
the contract requested for will replace Licensed Agent Signature
existing annuities or insurance? / / Yes / / No
----------------------------------------------------------------------------
First Name MI Last Name
----------------------------------------------------------------------------
Broker/Dealer Broker/Dealer Street Address City State ZIP
----------------------------------------------------------------------------
Business Telephone Number Fax Number Licensed Agent SSN
----------------------------------------------------------------------------
Select Program*: / / A / / B / / C
*Contact your back office for Program
information. (Option is irrevocable)
[Broker/Dealer Client Account Number License I.D. (Florida Agents Only)]
___________________________________ __________________________________
↑Top
Filing Submission 0000912057-02-038114 – Alternative Formats (Word / Rich Text, HTML, Plain Text, et al.)
Copyright © 2024 Fran Finnegan & Company LLC – All Rights Reserved.
About — Privacy — Redactions — Help —
Tue., May 14, 4:13:35.1pm ET 