AUL/Application to Group Annuity 457 APPLICATION TO THE AMERICAN UNITED LIFE INSURANCE COMPANY
FOR A GROUP ANNUITY CONTRACT
City of Carmel
(hereinafter called the Applicant)
hereby applies for Group Annuity Contract Number G 76.040.
This application is made a part of the said contract, which is hereby approved and its provisions and
•
conditions accepted.
This application is executed in duplicate, one counterpart being attached to said contract and the other being
returned to American United Life Insurance Company.
It is agreed that this application supersedes any previous application for said contract.
Dated at oti
Signature of Applicant City of Carmel
By- Signature Page Attached
(Soliciting Agent)
(Signature and Title)
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
• false information in an application for insurance is guilty of a crime and may be subject to civil lines and criminal
Penalties.
P-11104
•
APPLICATION TO THE AMERICAN UNITED LIFE INSURANCE COMPANY
FOR A GROUP ANNUITY CONTRACT
City of Carmel
(hereinafter called the Applicant)
hereby applies for Group Annuity Contract Number G 76.040.
This application is made a part of the said contract, which is hereby approved and its provisions and
conditions accepted.
This application is executed in duplicate, one counterpart being attached to said contract and the other
being returned to American United Life Insurance Company.
It is agreed that this application supersedes any previous application for said contract.
Dated at on
Signature of Applicant City of Carmel
Signature Page Attached
By_
(Soliciting Agent)
(Signature and Title)
Any person who knowingly presents a fa/.se or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crone and may he subject to civil fines and criminal
penalties.
P-11/04
.
•
CITY OF CARMEL, INDIANA
By and through its Board of Public Works and Safety
11-77-13
James Brain d, Presiding Officer Date
4-"A
Mary Burke, Member Date
Lori Watson, Bt
Date
ATTE T:
4A4 A �/ j `' /7-
)iana Cordray, IAMC, Clerk-Treasurer Date