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Apply for a Fixed Annuity

Owner If IRA or TSA, the owner and annuitant must be the same person

Joint Owner Not available with qualified plans

Annuitant Complete if different than owner. If IRA or TSA, the owner and annuitant must be the same person

Beneficiary Designation A Date of Birth or SSN is required for each beneficiary. Complete Additional Beneficiary Page if additional space is needed. Unless otherwise specified, all beneficiaries in the same class will share equally. Allocations must total up to 100% and must be indicated in whole percentages

Applied For Annuity Not all products may be available in all states. Check product availability for your state

Qualified If qualified, check the type of plan applied for. (Simple IRA’s not available.) Inherited IRA is only allowed for spouse beneficiary

Total Expected Premium

*Complete for Salary Deduction selection:

Premium Payor Complete if different than owner

Equity Indexed Annuity Allocation Only complete for applicable annuity products when appropriate. Indexed crediting strategies are based on the declared index. Whole percentages must be used. The total percent must equal 100%.

Point to Point Allocations (Minimum $100 Per Allocation)

S&P 500® Index One Year Point to Point Performance with a Cap.

S&P 500® Index One Year Point to Point Performance with a Cap

S&P 500® Index One Year Point to Point Uncapped

S&P MARC 5% Index One Year Point to Point Uncapped

NASDAQ-100 Index® One Year Point to Point Performance with a Cap

Monthly Sum Allocation (Minimum $100 Per Allocation)

S&P 500® Index One Year Total Sum Performance with Monthly Cap

Annual Allocations (Minimum $100 Per Allocation)

One Year Declared Rate

S&P 500® Index One Year Performance with Specified Rate

Optional Rider Selection Available at issue only. Not all riders may be available in all states. Check rider availability for your state

Immediate Annuity Income Options

Optional Cost of Living Adjustment

Joint Life Annuitant Information (if applicable)

Payment Information

Total Insurance / Annuities In Force On Owner

Fraud Warning - Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

Application Agreements - By signing this application I agree to the following: • If applying for an Equity Indexed annuity, I understand that: • I am applying for an Equity Indexed annuity. While the values of the contract may be affected by an external index, the contract does not directly participate in any stock or equity investments; I am not buying an ownership interest in any stock or index. • Any values shown, other than guaranteed minimum values, are not guarantees, promises, or warranties. • I have read the application and all statements and answers as they pertain to me and such statements and answers are true and complete to the best of my knowledge and belief; • The statements and answers in this application are the basis for any contract issued by American National and no information about any person in the application will be considered to have been given to American National unless it is stated in the application; • I understand that the producer does not have American National’s authorization to accept risk, pass on insurability, or make, void, waive, or change any conditions or provisions of this application or the contract; • American National Insurance Company will have no liability until: • A contract is issued on this application and delivered to and accepted by the Owner; and • The first premium due is paid in full while each proposed owner and annuitant is alive; • I understand that federal law requires sufficient information to identify the parties to the purchase of an annuity, and that failure to provide such information could result in the annuity contract not being issued, delayed, unprocessed transaction requests, or termination.

Producer’s Report - NOTE: These questions must be answered in every case:

Product and Commission Selection Please select the product being applied for and the desired commission option. If no option is selected, the default option will be Option A. Trail commissions begin in policy year two and continue for as long as the policy is in force. Trail commissions are based upon a percentage of the policy account value. See commission schedule for percentage paid

Producer Information

Producers Commission Split List Name and Personal Code of all Producers, besides yourself, entitled to any commission with appropriate percentage