ANNUITY AMERICAN FIDELITY ASSURANCE COMPANY APPLICATION 9000 Cameron Parkway Oklahoma City, Oklahoma 73114 PROPOSED ANNUITANT
INFORMATION First Name Middle Name Last Name Suffix Employment Date Date of Birth Age Sex Social Security Number E-Mail Address (if any) Residence Address (Street and Number) Work Phone #, Ext. # Home Phone #
( ) ( ) City State Zip Mailing Address (Street, Number, or PO Box, City, State, and Zip, if different than Residence) Employer Annual Salary Occupation $ POLICY OWNER(S) (COMPLETE IF OTHER THAN ANNUITANT) First Name Middle Name Last Name Suffix Date
of Birth SSN or Tax ID # Sex Relationship to Annuitant Residence Address (Street and Number) City State Zip Mailing Address (Street, Number, or PO Box, City, State, and Zip, if different than Residence) E-Mail
Address (if any) Joint Owner First Name Middle Name Last Name Suffix Date of Birth SSN or Tax ID # Sex Relationship to Joint Owner Residence Address (Street and Number) City State Zip Mailing Address (Street, Number, or PO Box, City, State, and Zip,
if different than Residence) E-Mail Address (if any) BENEFICIARY INFORMATION Primary: (First, Middle, and Last Name) SSN or Tax ID # Date of Birth Relationship Contingent: (First, Middle, and Last Name) SSN or
Tax ID # Date of Birth Relationship PLAN INFORMATION Type of Plan (Choose One): 403(b) Options Traditional IRA Options Roth IRA Options No Plan 403(b) TIRA RIRA Non-Qualified 403(b)Roth SEP IRA RIRA Conversion
Other BILLING INFORMATION Select one ( if applicable) Additional Payment ( if any) Requested Effective Date Employee: List Bill Lump Sum* Employer: Date of first deduction/payment Bank Draft (Attach first month premium Transfer, Rollover, Billing
Mode: and authorization) or 1035 Exchange* Employee Employer Direct Bill * (Paper work must be completed) MCP#: Date of first payment Employee Employer A1218 Page 1 of 3
PERIODIC PAYMENT INFORMATION This is an application for a Flexible Premium Deferred Annuity. If your premium amount changes and we have
not received instructions as to how to apply the new amount, it will be applied in the same proportion and manner as per your instructions below. PAYMENTS FOR OFFICE USE ONLY Employee EE Employer ER Fixed Annuity Add HIO $ $ Fixed Annuity with HIO $
$ AFPR1ME GROWTH® Variable Annuity $ $ AFAdvantage Variable Annuity® $ $ Total Payment $ $ Special Instructions: AFAdvantage Variable Annuity® INVESTMENT OPTION ALLOCATIONS (Enter whole percentages only, must total 100%. The dollar
amount allocated to each option cannot be less than $ 25.00.) DO NOT COMPLETE FOR THE AFPR1ME GROWTH® VARIABLE ANNUITY OR THE FIXED ANNUITY. EE ALLOCATION INVESTMENT OPTIONS ER ALLOCATION % AFGI American Fidelity Guaranteed Interest Account % %
VG01 Vanguard® VIF Total Bond Market Index Portfolio % % VG02 Vanguard® VIF Balanced Portfolio % % AM02 American Funds IS Washington Mutual Investors Fund % % DR01 BNY Mellon Stock Index Fund, Inc. % % VG05 Vanguard® VIF Total Stock
Market Index Portfolio % % DR02 BNY Mellon Sustainable U.S. Equity Portfolio, Inc. % % VG04 Vanguard® VIF Capital Growth Portfolio % % VG06 Vanguard® VIF Mid-Cap Index Portfolio % % DR07 BNY Mellon VIF
Opportunistic Small Cap Portfolio % % AM01 American Funds IS International Fund % Total 100 % Total 100 % A1218 Page 2 of 3
GENERAL INFORMATION Yes No 1. Is every Annuitant, Beneficiary(s), Premium Payor, and Policy Owner(s) a citizen of the United States? If
No, who is not? Place/country of citizenship? Attach a copy of the current valid VISA or Alien Registration Receipt Card OR provide card number. 2. a. Does the Annuitant have any existing coverage or pending applications for individual life
insurance or annuities with this or any other company? b. Does the Annuitant intend to replace, discontinue or change any such coverage? If YES to a. or b. provide the following information, and complete and return any required replacement forms.
Person Covered Amount Company Name Policy Number SIGNATURES FOR VARIABLE ANNUITIES ONLY: With my signature below, I am certifying that I received a prospectus for the Variable Annuity policy for which I have applied. I was given the opportunity to
receive this information either in paper format, or electronic format (by CD-Rom, E-Mail or Internet). I understand that all payments and values provided under a
variable annuity contract are based on the investment experience of a separate account and are not guaranteed as to fixed dollar amount. FOR 403(b) ONLY: I understand the withdrawal restrictions under Internal Revenue Code section 403(b)(11) on
contributions and earnings. I also understand that the withdrawal of my contributions is limited by my attainment of age 59 1⁄2, death, disability (as defined in
Section 72(m)(7) of the Code) and financial hardship. WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a claim for the proceeds of an insurance policy containing any false, incomplete or
misleading information or knowingly presents false information may be guilty of insurance fraud. Signed At (City and State) Date Signed Signature of Joint Owner (if applicable) Signature of Owner Driver’s License or Government Issued ID Type
and Number: Driver’s License or Government Issued ID Type and Number: Issued By: Expiration Date: Issued By: Expiration Date: AGENT STATEMENT: To the best of my knowledge the proposed insured does does not have any existing life insurance or
annuity; and, the proposed insured does does not intend to replace, discontinue or change any such coverage. I have reasonable grounds for believing that the recommendations for this Annuitant/Policy Owner to purchase/exchange or replace an annuity
is suitable. This recommendation was based on facts disclosed to me, either orally or in writing, as to their retirement objectives, other insurance products, and their financial situation and needs. Signature of Agent/Witness (Licensed resident
agent where required by law) Agent # A1218 Page 3 of 3