Kemper Investors Life Insurance Company Variable Annuity Application Form

Summary

This document is an application form for a variable annuity contract offered by Kemper Investors Life Insurance Company (KILICO), under the Zurich Preferred Plus Annuity program. The form collects information about the annuitant, owner, and beneficiaries, as well as investment allocations, plan type (such as IRA or non-qualified), and asset rebalancing preferences. It also includes suitability questions to assess the applicant's financial situation and investment risk profile. The application is used to initiate a variable annuity contract between the applicant and KILICO.

View More
EX-4.(J) 11 0011.txt FORM OF VARIABLE ANNUITY APPLICATION EXHIBIT 5.2 Kemper Investors Life Insurance Company (KILICO) 1 Kemper Drive, Long Grove, Illinois 60049-0001 [LOGO] - --------------------------------------------------------------------- ZURICH KEMPER
Zurich Preferred Plus Annuity Variable Annuity Application - ------------------------------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------- ------------------------------------------------------------- 1. Annuitant Information 2. Owner Information - ------------------------------------------------------------- ------------------------------------------------------------- Please complete this section only if Owner(s) is other than Proposed Annuitant(s). Name of Annuitant Name of Owner - ------------------------------------------------------------- ------------------------------------------------------------- [_] Male [_] Female SS# [_] Male [_] Female SS# - ------------------------------------------------------------- ------------------------------------------------------------- Date of Birth Date of Birth - ------------------------------------------------------------- ------------------------------------------------------------- Address Address - ------------------------------------------------------------- ------------------------------------------------------------- City State Zip City State Zip - ------------------------------------------------------------- ------------------------------------------------------------- Email Address Email Address - ------------------------------------------------------------- ------------------------------------------------------------- Daytime Phone Daytime Phone - ------------------------------------------------------------- ------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------------------------------- 3 Beneficiary Information - ------------------------------------------------------------------------------------------------------------------------------- Please check box next to beneficiary name if the beneficiary is the spouse of the contract owner. (Each designation should equal 100%.) Use Section 11 for additional beneficiary(s). [_] Primary % DOB - ------------------------------------------------------------------------------------------------------------------------------- [_] Primary % DOB - ------------------------------------------------------------------------------------------------------------------------------- [_] Contingent % DOB - ------------------------------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------------------------------- 4. Type of Plan - ------------------------------------------------------------------------------------------------------------------------------- [_] Non-Qualified [_] Roth IRA [_] 408(b) IRA [_] Simple IRA [_] 403 [_] 401 [_] 457 The annuitant has received, read and understands the IRA Disclosure Statement. (Included in the Zurich Preferred Plus prospectus.) _______________ Tax Year of Initial Contribution (if you selected either a 408(b) IRA or Roth IRA). - ------------------------------------------------------------------------------------------------------------------------------- 5. Subaccount Options (Use Form L-8710 for Portfolio Selections within the MIAA Program) - ------------------------------------------------------------------------------------------------------------------------------- Total Allocation must equal 100%. International Stock Miscellaneous Fixed Income Large Cap U.S. Stock ___ % Janus Aspen Series ___ % Kemper High Yield ___ % Kemper Growth Worldwide Growth ___ % Kemper Money Market ___ % Fidelity VIP Growth ___ % Scudder International ___ % Fidelity VIP Equity-Income Kemper General Account ___ % Fidelity VIP II Index 500 U.S. Broad Fixed Income ___ % Fixed Account ___ % Fidelity VIP II Contrafund ___ % Kemper Investment ___ % Janus Aspen Series Growth Grade Bond Other ___ % Alger American Growth ___ % Kemper Government ___ % ________________________ ___ % Scudder Capital Growth Securities ___ % ________________________ ___ % American Century Income ___ % Scudder Bond ___ % ________________________ & Growth ___ % ________________________ Emerging Markets Small/Mid Cap U.S. Stock ___ % Warburg Pincus MVA Guarantee Period ($5,000 Min.) ___ % Kemper Small Cap Growth Emerging Markets ___ % ________________________ year ___ % American Century Value ___ % ________________________ year ___ % J.P. Morgan Small Company Specialty Stock ___ % ________________________ year ___ % Alger American Small Cap ___ % Kemper Technology ___ % ________________________ year ___ % Alger Mid Cap ___ % Dreyfus Socially ___ % Janus Aspen Series Responsible Growth DCA Account (Complete DCA form) Aggressive Growth Balanced ___ % ________________________ months ___ % Kemper Total Return ___ % ________________________ months ___ % Janus Aspen Series Balanced
L-8704 - ----------------------------------------------------------------------------------------------------------------------------------- 6. Automatic Asset Rebalancing - ----------------------------------------------------------------------------------------------------------------------------------- MVA options excluded. [_] I elect Automatic Asset Rebalancing (AAR) amount the subaccounts listed below: Every: [_] 1 Month [_] 3 Months [_] 6 Months [_] 12 Months Beginning _______/______/__________ or [_] at contract issue Target Allocations Total allocation must equal 100%. [_] Same allocations as Section 5. Large Cap U.S. Stock International Stock Specialty Stock ____% Kemper Growth ____% Janus Aspen Series ____% Kemper Technology ____% Fidelity VIP Growth Worldwide Growth ____% Dreyfus Socially ____% Fidelity VIP Equity-Income ____% Scudder International Responsible Growth ____% Fidelity VIP II Index 500 ____% Fidelity VIP II Contrafund U.S. Broad Fixed Income Balanced ____% Janus Aspen Series Growth ____% Kemper Total Return ____% Alger American Growth ____% Kemper Investment ____% Janus Aspen Series Balanced ____% Scudder Century Income Grade Bond ____% American Century Income ____% Kemper Government Miscellaneous Fixed Income & Growth Securities ____% Kemper High Yield ____% Scudder Bond ____% Kemper Money Market Small/Mid Cap U.S. Stock ____% Kemper Small Cap Growth Emerging Markets ____% American Century Value ____% Warburg Pincus Other ____% J.P. Morgan Small Company Emerging Markets ____% ____________________ ____% Alger American Small Cap ____% ____________________ ____% Alger Mid Cap Kemper General Account ____% ____________________ ____% Janus Aspen Series Aggressive Growth ____% Fixed Account - ----------------------------------------------------------------------------------------------------------------------------------- 7. Suitability (must be completed by IBS representatives) - ----------------------------------------------------------------------------------------------------------------------------------- Income Employer Name - -------------------------------------------------------------- ---------------------------------------------------------------- Net Worth (exclusive of home) Occupation - -------------------------------------------------------------- ---------------------------------------------------------------- Tax Bracket Number of Dependents Is the contract owner associated with the NASD? - -------------------------------------------------------------- Risk Factors (check one): [_] Yes [_] No [_] Conservative [_] Moderate If so, how? [_] Aggressive [_] Speculative ---------------------------------------------------------------- - -------------------------------------------------------------- Is the contract owner associated with the broker/dealer? Financial Objectives (check one): [_] Yes [_] No [_] Long Term Growth [_] Short Term Growth [_] Income If so how? [_] Tax Advantage [_] Capital Preservation - -------------------------------------------------------------- ---------------------------------------------------------------- Must be completed by non-IBS representatives: [_] Suitability information has been obtained and filed with the broker/dealer. - ----------------------------------------------------------------------------------------------------------------------------------- 8. Account Access Authorization - ----------------------------------------------------------------------------------------------------------------------------------- The owner of this contract has access to his/her contract via interactive voice response system, client services representatives, and Internet service system. Check all that apply. [_] I hereby authorize the servicing sales representative to make changes to my account. [_] I hereby authorize my spouse __________________________________________________________________ to make changes to my account. [_] I hereby authorize ____________________________________________________________________________ to make changes to my account. - ----------------------------------------------------------------------------------------------------------------------------------- 9. Annuitization - ----------------------------------------------------------------------------------------------------------------------------------- The annunity date will be the annuitant's 95th birthday unless another year is requested here:____________________________________ - ----------------------------------------------------------------------------------------------------------------------------------- 10. Replacement Compliance - ----------------------------------------------------------------------------------------------------------------------------------- Is this annuity intended to replace or change any existing life insurance or annuity? [_] Yes [_] No - ----------------------------------------------------------------------------------------------------------------------------------- 11. Special Requests - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------- - -----------------------------------------------------------------------------------------------------------------------------------
L-8704 - -------------------------------------------------------------------------------------------------------------------------------- 12. Contribution Information - -------------------------------------------------------------------------------------------------------------------------------- Are you applying for scheduled periodic payments through payroll deduction? [_] Yes [_] No How much will you be contributing each payroll period? _________________________________________________________________________ Gross Annual Salary $__________________________________________________________________________________________________________ Employer Contribution (if applicable) Dollar or % amount each payroll period ___________________________________________________ Frequency of employer contribution _____________________________________________________________________________________________ - -------------------------------------------------------------------------------------------------------------------------------- 13. IMPORTANT - Delivery of Regulatory Documents - -------------------------------------------------------------------------------------------------------------------------------- We will send you an updated prospectus for your annuity contract on an annual basis. We will also send you semi-annual reports for the subaccounts in which you are invested. (Check only one) [_] I agree to have my prospectus updates, semi-annual and annual reports delivered on a IBM system compatible diskette. [_] I wish to have my prospectus updates, semi-annual and annual reports delivered by e-mail. I understand that I may incur on-line charges. [_] I wish to have paper copies of prospectus updates, semi-annual and annual reports mailed to me. I understand I may revoke my electronic consent at any time by calling ###-###-####. - -------------------------------------------------------------------------------------------------------------------------------- 14. Signatures - -------------------------------------------------------------------------------------------------------------------------------- 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. Withdrawals and transfers from a Guarantee Period that are made prior to the end of that Guarantee Period are subject to a Market Value Adjustment that may increase or decrease the Contract Value. 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. [_] Please check here to acknowledge receipt of a current prospectus for the Kemper Investors Fund and the KILICO Variable Annuity Separate Account. [_] Please check here if you would like to receive a Statement of Additional Information. 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. Application made at (City) (State) (Date) - -------------------------------------------------------------------------------------------------------------------------------- Signature of Owner - -------------------------------------------------------------------------------------------------------------------------------- - -------------------------------------------------------------------------------------------------------------------------------- 15. Agent's Report - -------------------------------------------------------------------------------------------------------------------------------- Is the annuity intended to change or replace any existing life insurance or annuity? [_] Yes [_] No If yes, please indicate annuity or life insurance below, enter the qualification code and submit any required replacement forms. [_] Life Insurance [_] Annuity Qualification Code ____________________________________________________________ Signature of Agent Daytime Phone - -------------------------------------------------------------------------------------------------------------------------------- Agent Name Agent Number - -------------------------------------------------------------------------------------------------------------------------------- Name and Address of Firm - -------------------------------------------------------------------------------------------------------------------------------- City State Zip - -------------------------------------------------------------------------------------------------------------------------------- - -------------------------------------------------------------------------------------------------------------------------------- 16. Plan Information (to be completed by agent) - -------------------------------------------------------------------------------------------------------------------------------- Is this application for an existing ZKL group? [_] Yes Supply group number ________________ Bill number _______________________ [_] No Please also complete the Employer Information and Billing Request Form ZKL-6571.
L-8704