Section 457

Group Variable Annuity

AMERICAN FIDELITY ASSURANCE COMPANY

Master Application

9000 Cameron Parkway

Oklahoma City, OK 73114

 

SECTION 457 DEFERRED COMPENSATION PLAN

GROUP POLICYHOLDER INFORMATION

 

 

Name of Policyholder (Employer or Plan):		Employer/Plan Tax Identification #:

 

Address of Policyholder (Street):

 

City		State		Zip

 

PLAN INFORMATION

 

This contract will be issued to the Employer for Section 457 Eligible Deferred Compensation Plan funding. Neither American Fidelity Assurance Company nor any of its agents is a party to the Employer’s Plan. The Group Variable Annuity Contract issued by American Fidelity Assurance Company to the Policyholder shall constitute the entire agreement between the Policyholder and American Fidelity Assurance Company.		REQUESTED
		EFFECTIVE DATE:
		FOR OFFICE USE ONLY

SPECIAL INSTRUCTIONS:    

 

WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE GUILTY OF INSURANCE FRAUD.

I UNDERSTAND THAT ALL PAYMENTS AND VALUES PROVIDED BY THE CONTRACT BEING APPLIED FOR ARE BASED ON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT. THE VALUES ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT.

WITH MY SIGNATURE BELOW, I ACKNOWLEDGE THAT PROSPECTUSES CONTAINING PRODUCT AND INVESTMENT OPTION INFORMATION WERE PROVIDED TO ME, AND WILL BE MADE AVAILABLE TO ELIGIBLE PLAN PARTICIPANTS. I WAS GIVEN THE OPPORTUNITY TO RECEIVE THIS INFORMATION EITHER IN PAPER FORMAT, OR IN ELECTRONIC FORMAT (BY CD-ROM, E-MAIL OR INTERNET).

 

Signed At						Date Signed
Signature of Witness						Name of Policyholder (Employer or Plan)		(Print)
(licensed resident agent where required)
						Authorized Signature
Agent Number:
						Print Name		Title

 

A-1176(R0503)