Vision Illustrator

Product	State	Premium	Type of Funds
--- Please Select a Product --- Allianz Life Insurance Company of North America Fixed Indexed Annuity Allianz 360 Annuity Allianz 365i Annuity Endurance Elite 5 Endurance Plus MasterDex 10 Plus Annuity MasterDex 5 Plus Annuity MasterDex X Annuity MYGA Dominator Plus 10 Dominator Plus 5 American National Insurance Company Fixed Indexed Annuity ANICO EIA ANICO Strategy Indexed Annuity 10 ANICO Strategy Indexed Annuity 7 Value Lock 10 Value Lock 7 MYGA Palladium MYG Annuity 10 Palladium MYG Annuity 5 Palladium MYG Annuity 6 Palladium MYG Annuity 7 Palladium MYG Annuity 8 Palladium MYG Annuity 9 Annexus (Aviva Life & Annuity) Fixed Indexed Annuity Balance Allocation Annuity 12 Balance Allocation Annuity 12 - 6% Bonus Balance Allocation Annuity 8 Balance Allocation Annuity 8 - 4% Bonus Balance Allocation Annuity 8S Balance Allocation Annuity 8S - 4% Bonus Aviva Life & Annuity (Income Series) Fixed Annuity Income Select Spirit 3 (1-Year) Income Select Spirit 5 (1-Year) Income Select Spirit 7 (1-Year) Income Select Spirit Bonus (1-Year) Income Select Spirit Plus Fixed Indexed Annuity Income Preferred Bonus Income Preferred Bonus Pro Income Preferred Bonus S Income Preferred Six Income Preferred Ten Income Select 10 Income Select 5 Income Select 7 Income Select Plus S Lifetime Solutions Annuity Aviva Life & Annuity (MultiChoice Series) Fixed Annuity Freedom 3 (1-Year) Freedom 5 (1-Year) Freedom 7 (1-Year) Freedom Plus (1-Year) Freedom Plus (1-Year) S Freedom Xtra (1-Year) Fixed Indexed Annuity MulitChoice Xtra Pro MultiChoice Advantage MultiChoice Income Five MultiChoice Income Plus MultiChoice Income Plus S MultiChoice Income Seven MultiChoice Income Ten MultiChoice Income Xtra MultiChoice Six MultiChoice Ten MultiChoice Xtra MultiChoice Xtra (S) EquiTrust Life Insurance Company Builder Bonus Index Market Booster Index Market Power Bonus Index Market Ten Bonus Index Market Value Index MarketTwelve Bonus MYGA Certainty 10 Certainty 8 Certainty Select 10 Certainty Select 5 Certainty Select 6 Certainty Select 8 Great American Life Insurance Company Fixed Indexed Annuity American Legend II American Valor II American Valor® 10 Safe Outlook Safe Return ING Annuity and Asset Sales ING Envoy Nine Fixed Index Annuity ING Secure Index Five ING Secure Index Opportunities Plus ING Secure Index Outlook Annuity ING Secure Index Seven Midland National Life Capstone 10 Capstone 14 Capstone 7 Innovator Choice 10 Innovator Choice 14 Innovator Choice 7 MNL EndeavorSM 12 MNL EndeavorSM 12 Plus MNL EndeavorSM 4 MNL EndeavorSM 6 MNL EndeavorSM 8 MNL EndeavorSM 8 Plus MNL MainStreet Four MNL Paragon Plus 10 MNL Paragon Plus 14 MNL Pargon Plus 7 MNL RetireVantageSM 10 MNL RetireVantageSM 10 OABR MNL RetireVantageSM 14 MNL Ten Prosperity Choice 10 Prosperity Choice 14 Prosperity Choice 7 Select Series (5%) 10 Select Series (5%) 14 Select Series (5%) 6 Select Series (5%) 8 Select Series 10 Select Series 14 Select Series 6 Select Series 8 MYGA Guarantee Ultimate 10 Guarantee Ultimate 4 Guarantee Ultimate 5 Guarantee Ultimate 6 Guarantee Ultimate 7 Guarantee Ultimate 8 Guarantee Ultimate 9 North American Company Fixed Indexed Annuity Charter 10 Charter 10 (TX) Charter 14 Charter 14 (TX) Charter 7 Charter 7 (TX) Freedom Choice (5%) 10 Freedom Choice (5%) 14 Freedom Choice (5%) 6 Freedom Choice (5%) 8 Freedom Choice 10 Freedom Choice 14 Freedom Choice 6 Freedom Choice 8 NA Performance Choice 12 NA Performance Choice 12 Plus NA Performance Choice 8 NA Performance Choice 8 Plus North American Formula Choice North American Formula Choice (TX) North American Paramount Choice Ten North American Prizm Plus 10 North American Prizm Plus 14 North American Prizm Plus 7 North American Ten Pillar Precision 10 Precision 10 (TX) Precision 14 Precision 7 Precision 7 (TX) MYGA Guarantee Choice 10 Guarantee Choice 3 Guarantee Choice 4 Guarantee Choice 5 Guarantee Choice 6 Guarantee Choice 7 Guarantee Choice 8 Guarantee Choice 9	- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY	$	Non-Qualified Qualified

Client Information

First Name	Last Name	Gender	Date of Birth
		- Select - Male Female	mon 1 2 3 4 5 6 7 8 9 10 11 12 / day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 /  Year 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Use Age Use Birth Date

Agent Information

First Name	Last Name

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