Kemper Investors Life Insurance Company Scudder Destinations II Application Form

Summary

This document is an application form for purchasing a Scudder Destinations II annuity contract from Kemper Investors Life Insurance Company, administered by Zurich Life Insurance Company. The applicant provides personal information, selects beneficiaries, specifies the initial payment, chooses the type of retirement or investment plan, and may elect optional riders for additional benefits. The form also allows for allocation of funds among various investment options and sets up features like dollar cost averaging and systematic accumulations. The agreement outlines the applicant's choices and obligations for establishing the annuity contract.

EX-4.J 11 dex4j.txt FORM OF APPLICATION Exhibit 4(j) Kemper Investors Life Insurance Company SCUDDER DESTINATIONS II Overnight Mail: Zurich Life Insurance Company, 200 W Monroe Suite 200 Attn: Lockbox Processing Dept 5021, Chicago, IL 60606 Please Print Clearly Regular Mail: Zurich Life Insurance Company 135 LaSalle Street Dept.5021, Chicago, IL 60674 1. Owner =============================================================================================== ------------------------------------------------- ------------------------------------ Name (First, Middle, Last) or Name of Trust Social Security/Tax I.D. Number ------------------------------------------------- ------------------------------------ Street Address Date of Birth/Trust ------------------------------------------------- [_] Male [_] Female City, State, Zip ( ) ------------------------------------------------- ------------------------------------ Daytime Telephone E-mail Address (Optional) ------------------------------------------------------------------------------------------ 2. Joint Owner =============================================================================================== ------------------------------------------------- ------------------------------------ Name (First, Middle, Last) Social Security/Tax I.D. Number ------------------------------------------------- ------------------------------------ Street Address Date of Birth ------------------------------------------------- [_] Male [_] Female City, State, Zip ( ) ------------------------------------------------- Daytime Telephone ------------------------------------------------------------------------------------------ 3. Annuitant =============================================================================================== ------------------------------------------------- ------------------------------------ Name (First, Middle, Last) Social Security/Tax I.D. Number ------------------------------------ [_] Male [_] Female Date of Birth - ----------------------------------------------------------------------------------------------- 4. Joint Annuitant =============================================================================================== ------------------------------------------------- ------------------------------------ Name (First, Middle, Last) Social Security/Tax I.D. Number ------------------------------------ [_] Male [_] Female Date of Birth - ----------------------------------------------------------------------------------------------- 5. Beneficiaries (For Additional Beneficiaries, use Section 17): =============================================================================================== * If there Joint Owners, the survivor is always the Primary Beneficiary. If Beneficiary is a trust, provide the date of when the trust was established. All Beneficiaries' allocations must total 100%. Name Primary or Contingent Relationship to Owner Allocation ------------------ --------------------------- ------------------------ ------------------ % ------------------ --------------------------- ------------------------ ------------------ % ------------------ --------------------------- ------------------------ ------------------ % ------------------ --------------------------- ------------------------ ------------------ % - ----------------------------------------------------------------------------------------------- 6. Initial Payment =============================================================================================== $ -------------------------------------------------------------------------------------------- (Make check payable to Kemper Investors Life Insurance Company) - ----------------------------------------------------------------------------------------------- 7. Type of Plan to Be Issued =============================================================================================== [_] Non-qualified [_] Non-qualified Def. Comp [_] SEP-IRA [_] 401 (K) Profit Sharing [_] 401 (a) Pension/Profit Sharing [_] Roth IRA [_] 403 (b) TSA [_] IRA [_] 457 Def. Comp [_] Charitable Remainder Trust - ----------------------------------------------------------------------------------------------- 8. Optional Riders =============================================================================================== I/We elect the following and understand there is/are additional charge(s): [_] Earnings Based Death Benefit Rider GRIB- Guaranteed Retirement Income Benefit [_] Value Credit Rider [_] 7 Year [_] 10 Year - -----------------------------------------------------------------------------------------------

L-8744 Dest-10 9. Allocation of Payment:
- ------------------------------------------------------------------------------------------------------------------------------------ Alger Scudder(continued) Scudder(continued) Kemper Investors Life Ins. Co. ______ % Balcd ________ % Cont Val ______ % Strge Inc ______ % Fxd Acct ______ % I.v All Cap ________ % Glb Bl Chp ______ % Tech Gro ______ % 3 mos. DCA Credit Suisse Warburg ________ % Glb Disc ______ % Total Ret ______ % 6 mos. DCA Pincus Trust ________ % Gov Sec ______ % 21st Cent Gro ______ % 12 mos. DCA ______ % Em Mkts ________ % Growth SVS (subadvised) ______ % 18 mos. DCA ______ % Glb Pst Vtr Cp ________ % Gro & Inc ______ % SVS Drm Fin (Dreman) Dreyfus ________ % Health Sens ______ % SVS Drm Hi (Dreman) GPA's ______ % Mid Cp Srk ________ % High Yld ______ % SVS Dynmc Gro (Invesco) ______ % 1 Yr _____ % 6 Yr ______ % Soc Rp Gro ________ % Int'l ______ % SVS Fc LC Gro (Eagle) ______ % 2 Yr _____ % 7 Yr ________ % Int'l Rsrch ______ % SVS Foc Val + Gro (ZSI/Jnsn) ______ % 3 Yr _____ % 8 Yr Invesco ________ % Inv Grd Bd ______ % SVS Gro & Inc (Janus) ______ % 4 Yr _____ % 9 Yr ______ % VIF Utilities ________ % Money Mkt I ______ % SVS Gro Opp (Janus) ______ % 5 Yr _____ % 10 Yr Scudder ________ % Money Mkt II ______ % SVS Indx 500 (Deutsche) ______ % Agg Gro ________ % New Euro ______ % SVS MC Gro (Turner) ______ % BL Chip ________ % SC Grow ______ % SVS Strgc Eq (Oak) ______ % Cap Gro ________ % SC Val ______ % SVS Ventr Val (Davis) (All allocations above must total 100%, $500 min.per account.) - ------------------------------------------------------------------------------------------------------------------------------------
10. Dollar cost Averaging (For Additional Subaccounts, use Section 17): - ------------------------------------------------------------------------------------------------------------------------------------ (Not available with Automatic Account Rebalancing, DCA is not allowed from any GPAs.) [_] Please transfer $ __________________ from _____________________ OR [_] Please transfer interest only from the Fixed Account ($100 minimum) (enter one Subaccount (must maintain a $10,000 balance and or the fixed Account) continue DCA for at least one year) - ------------------------------------------------------------------------------------------------------------------------------------ Transfer To: Frequency: Every [_] 1 [_] 3 Months Subaccount # Percent Beginning: / / _________________________________ __________________________________ % ---------------- _________________________________ __________________________________ % Unless otherwise specified, DCA will occur each _________________________________ __________________________________ % period on the date the contract/certificate is issued _________________________________ __________________________________ % All allocations must total 100% - ------------------------------------------------------------------------------------------------------------------------------------
11. Systematic Accumulations: - ------------------------------------------------------------------------------------------------------------------------------------ [_] I authorize automatic deductions of $ __________________ from my Frequency: Every [_]1 [_]3 [_]6 [_]12 Months ($100 minimum) bank account to be applied to this contract beginning each period Beginning: / / ---------------- on the date the contract/certificate is issued, unless otherwise specified. Please attach a voided check or voided withdrawal slip. - ------------------------------------------------------------------------------------------------------------------------------------
12. Systematic Withdrawals (For Additional Subaccount, use Section 17): - ------------------------------------------------------------------------------------------------------------------------------------ [_] Please withdraw $ _______________ Frequency: Every [_]1 [_]3 [_]6 [_]12 Months ($100 minimum) Beginning: / / --------------- Withdrawal from: See form for automatic 70 1/2 minimum distributions. Subaccount # Percent Withdrawals before age 59 1/2 may be subject to a 10% IRS penalty. Please consult your tax advisor. _________________________________ __________________________________ % Funds allocated to a GPA are subject to a Market _________________________________ __________________________________ % Value Adjustment unless withdrawals are taken within _________________________________ __________________________________ % 30 days after the end of a Guarantee Period. _________________________________ __________________________________ % [_] I wish to use Electronic Funds Transfer (Direct Deposit). I authorize Kemper Investors Life Insurance [_] Do not withhold federal income taxes. Company (KILICO) to correct electronically any over- Please: [_] Do withhold at 10% of ______________ (%) payments or erroneous credits made to my account. Please attach a voided check tor voided deposit slip. - ------------------------------------------------------------------------------------------------------------------------------------
13. Automatic Asset Rebalancing - ------------------------------------------------------------------------------------------------------------------------------------ (Not available concurrently with DCA) [_] I elect Automatic Asset Rebalancing (AAR) among the above accounts Frequency: Every [_]1 [_]3 [_]6 [_]12 Months (excluding Fixed, GPA's and the Money Market II subaccount.) Beginning: / / --------------- Unless otherwise specified, rebalancing will occur each period on the date the contract/certificate is issued to the allocation selected in section 9 of this application. - ------------------------------------------------------------------------------------------------------------------------------------
14. "Protect Your Future" Program: [_] Allocate a portion of my initial payment to the ___________ year GPA such that, at the end of the Guarantee Period, the GPA will have grown to an amount equal to the total initial payment assuming no withdrawals or transfers of any kind. The remaining balance will be applied as indicated in section 9. - -------------------------------------------------------------------------------- 15. Telephone Authorization: I authorize and direct Kemper Investors Life Insurance Company (KILICO) to accept telephone instructions from the owner, active representative, and the individual listed below to effect transfers and/or future payment allocation changes. I agree to hold harmless and indemnify KILICO and its affiliates and their collective directors, employees and representatives against any claim arising from such action. ~~Name __________________________________________ __/__/____ [_] I do not accept this telephone transfer privilege. Birthdate~~

- ------------------------------------------------------------------------------- 16. Replacement Do you have any existing annuity contracts or life insurance policies? [_] No [_] Yes Will any existing life insurance or annuity be replaced or will values from another insurance policy or annuity (through loans, surrenders or otherwise) be used to pay premiums for the policy applied for? [_] No [_] Yes If yes, indicate company name and policy number________________ - -------------------------------------------------------------------------------- 17. Remarks. __________________________________________________________________________ __________________________________________________________________________ - -------------------------------------------------------------------------------- 18. Signatures: RECEIPT IS ACKNOWLEDGED OF THE CURRENT PROSPECTUS FOR KEMPER INVESTORS FUND AND THE KILICO VARIABLE ANNUITY SEPARATE ACCOUNT. PAYMENTS AND VALUES PROVIDED BY THE CONTRACT, WHEN BASED ON INVESTMENT EXPERIENCE OF THE SUBACCOUNTS, ARE VARIABLE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. [_] If you want a statement of additional information please check here. I agree that the above statements are true and correct to the best of my knowledge and belief and are made as a basis for my application. By signing this application, I agree to have my prospectus updates, semi- annual and annual reports delivered on a IBM system compatible diskette. Otherwise, if I do not consent to the diskette delivery, I elect the following: [_] I wish to have prospectus updates, semi-annual and annual reports delivered by e-mail. I understand that I may incur on-line charges. My e-mail address is:_____________________ (please ensure to inform KILICO of any e-mail address changes). [_] I wish to have paper copies of prospectus updates, semi-annual and annual reports mailed to me. I understand that I may revoke my electronic consent at any time by calling ###-###-####. ____________________________ ________________ ______________________ Application Made at (City) State Date _______________________________________________________________ _____________________________________________________ Signature of Participant (Owner unless otherwise indicated) Signature of Owner (If other than Participant) - ---------------------------------------------------------------------------------------------------------------------------

19. Registered Representative/Dealer Information: Does the owner have any existing annuity contracts or life insurance policies? [_] No [_] Yes (attach replacement forms as required) To the best of your knowledge will any existing life insurance or annuity be replaced or will values from another insurance policy or annuity (through loans, surrenders or otherwise) be used to pay premiums for the policy applied for? [_] No [_] Yes I certify that the information provided by the owner has been accurately recorded; current prospectuses were delivered; no written sales materials other than those approved by the Principal Office were used; and I have reasonable grounds to believe the purchase of the contract applied for is suitable for the owner. Suitability information has been obtained and filed with the broker/dealer. ___________________ ____________________________________________ ______________________ __________________________ ___________________ Signature of Registered Representative Telephone Number Social Security Number Comm. Code ___________________ ____________________________________________ ___________________________________________________ ___________________ Printed Name of Registered Representative Printed Name of Broker/Dealer B/D Client Acct # ____________________________________________________________________________ _____________________________________________ Branch Office Street Address for Contract Delivery Zurich Life Representative Number

- ------------------------------------------------------------------------------- Overnight Mail: Zurich Life Insurance Company, 200 W Monroe, Suite 200, Attn: Lockbox Processing Dept. 5021, Chicago, IL 60606 Make check payable to: Kemper Investors Life Insurance Company