Transcription of The Director / Director Access / The Director …
1 Hartford Life SNAP Annuity Ticket for The Director M /. The Director M Outlook / The Director M Plus / Director M AccessSM /. CRC / CRC Select / Saver Plus . NOTE: SNAP Annuity Tickets MAY NOT be used in New York OR with 1035(a) Exchange/Qualified Transfer/Qualified Rollover Paperwork. A separate enrollment form is required to enroll in any Fixed Dollar DCA, Automatic Income/Distribution, or Electronic Funds Transfer (EFT) program. IMPORTANT: This ticket may NOT be processed if our licensing records indicate you are not properly appointed in the solicitation state. The solicitation state is the state in which the owner was located at the time the business was solicited. If the solicitation state is different from the residence state, please submit a Contract Situs Form. YES NO Is this transaction a replacement of an existing life insurance policy or annuity contract? State Business was Solicited: Date Solicited: New Account Additional Deposit: Contract # _____.
2 Firm Name: Firm Customer Account #: Investment Professional Name: Investment Professional SSN: Phone Number: Commission Option (Check One): The Director M A B C The Director M Plus A B Fixed Product Default is Fixed The Director M Outlook A B Director M Access Default is D. If no option is selected, the default commission option established by your Firm will be chosen. Variable Product Choice The Director M $_____ The Director M Plus $_____. The Director M Outlook $_____ Director M Access $_____. Fixed Product Choice (Additional deposits to existing contracts are not available). CRC Select1 $_____ CRC1 $_____ Saver Plus $_____. 5 Years 6 Years 7 Years 5 Years 6 Years 7 Years 5 Years 6 Years1. 8 Years 9 Years 10 Years 8 Years 9 Years 10 Years 7 Years 10 Years 1 Not available in MD, OR, WA 1 Onlyavailable in OR and WA 1 Not available in TX. Contract Owner Name: Date of Birth: SSN / TIN: M F. Contract Owner Address: City: State: Zip Code: Joint Contract Owner Name (if applicable): Date of Birth: SSN / TIN: M F.
3 Annuitant Name (if different from Contract Owner): Date of Birth: SSN / TIN: M F. Annuitant Address: City: State: Zip Code: Contingent Annuitant Name (if applicable): Date of Birth: SSN / TIN: M F. Name: Relationship to Owner: Primary Beneficiary _____ %. Primary Beneficiary Name: Relationship to Owner: Contingent Beneficiary _____ %. Form HL-19776-1 Printed in Page 1 of 3. Hartford Life SNAP Annuity Ticket (continued). Optional Death Benefit Election and Optional Feature Election* (Only one option in each section may be selected). MAV Plus (Not Available in MN and WA) Maximum Anniversary Value (MAV) (Available in MN and WA Only). The contract will receive a Standard Death Benefit at no additional charge. The MAV Plus and MAV options are available to purchasers age 75 or younger (oldest of Owners and Annuitant) for an additional annual charge deducted daily until we begin to make annuity payouts. The Hartford's Principal First Preferred 1 The Hartford's Principal First 1 The Hartford's Lifetime Income Builder 2.
4 (5% Benefit Payment) (7% Benefit Payment) (Not available in all states). 1 An additional annual charge, which varies by rider, is deducted on a daily basis until we begin to make annuity payouts. 2 An additional annual charge based on your then current Benefit Amount is automatically deducted on each contract anniversary until we begin to make annuity payouts. * Please refer to the prospectus for complete details on these Optional Benefits/Features and their corresponding charges. Non-Qualified Qualified: New Contribution Transfer Rollover If Qualified, indicate Tax Year:_____ (if applicable) and check off specific Plan Type below: IRA Roth IRA Custodial IRA SEP IRA SIMPLE IRA. 403(b) 401(a) 401(k) Other: _____. California Senior Protection Program Election: Required only if the Solicitation State is CA and any owner or annuitant is age 60 or older. California law now permits seniors to not bear investment risk during the examination period or to choose immediate equity market exposure.
5 I/we wish to immediately invest in the equity markets via my/our investment selection provided below. I/we wish to defer my/our investment selection via the Senior Protection Program. Investment Option Selection: For Portfolio Planner Asset Allocation Program Elections, please skip this section and complete the Portfolio Planner Asset Allocation Program Section on Page 3. _____% AllianceBernstein Balanced Wealth Strategy Portfolio _____% Hartford Value Opportunities HLS Fund _____% AllianceBernstein Global Research Growth Portfolio 1 _____% Lord Abbett All Value Portfolio _____% AllianceBernstein International Value Portfolio 1 _____% Lord Abbett America's Value Portfolio _____% AllianceBernstein Small/Mid Cap Value Portfolio _____% Lord Abbett Bond-Debenture Portfolio _____% AllianceBernstein Value Portfolio _____% Lord Abbett Large Cap Core Portfolio _____% Fidelity VIP Contrafund Portfolio _____% Lord Abbett Growth & Income Portfolio _____% Fidelity VIP Equity-Income Portfolio _____% Oppenheimer Aggressive Growth Fund/VA.
6 _____% Fidelity VIP Growth Portfolio _____% Oppenheimer Capital Appreciation Fund/VA. _____% Fidelity VIP Mid Cap Portfolio _____% Oppenheimer Global Securities Fund/VA1. _____% Fidelity VIP Value Strategies Portfolio _____% Oppenheimer Main Street Fund/VA. _____% Hartford Advisers HLS Fund _____% Oppenheimer Main Street Small Cap Fund/VA. _____% Hartford Disciplined Equity HLS Fund _____% Putnam VT Diversified Income Fund _____% Hartford Dividend and Growth HLS Fund _____% Putnam VT The George Putnam Fund of Boston _____% Hartford Equity Income HLS Fund _____% Putnam VT Global Asset Allocation Fund 1. _____% Hartford Focus HLS Fund _____% Putnam VT Growth and Income Fund _____% Hartford Global Advisers HLS Fund 1 _____% Putnam VT International Equity Fund 1. _____% Hartford Global Leaders HLS Fund 1 _____% Putnam VT Investors Fund _____% Hartford Growth HLS Fund _____% Putnam VT New Value Fund _____% Hartford Growth Opportunities HLS Fund _____% Putnam VT Small Cap Value Fund _____% Hartford High Yield HLS Fund _____% Putnam VT Vista Fund _____% Hartford Index HLS Fund _____% Putnam VT Voyager Fund _____% Hartford International Capital Appreciation HLS Fund 1 _____% Van Kampen Comstock Portfolio _____% Hartford International Opportunities HLS Fund 1 _____% Van Kampen Emerging Markets Equity Portfolio 1.
7 _____% Hartford International Small Company HLS Fund 1 _____% Van Kampen Growth and Income Portfolio _____% Hartford Money Market HLS Fund _____% Van Kampen Mid Cap Growth Portfolio _____% Hartford Mortgage Securities HLS Fund _____% Van Kampen Mid Cap Value Portfolio _____% Hartford SmallCap Growth HLS Fund _____% Fixed Accumulation Feature 1 2 3. _____% Hartford Stock HLS Fund _____% DCA Plus 6-Month Program 1 4 5. _____% Hartford Total Return Bond HLS Fund (Please provide Dollar Cost Averaging instructions on Page 3). _____% Hartford Government Securities HLS Fund _____% DCA Plus 12-Month Program 1 4 5. _____% Hartford Value HLS Fund (Please provide Dollar Cost Averaging instructions on Page 3). 100 % Total 1 Not available with the Director M Access . 2 Not available with the Director M Outlook or Director M Plus. 3 May be subject to state availability. 4 DCA Plus Rates may differ for The Director M Outlook and The Director M Plus.
8 5 Not available if deferral is elected within the California Senior Protection Program. Form HL-19776-1 Printed in Page 2 of 3. Hartford Life SNAP Annuity Ticket (continued). Annuitant Name: Annuitant SSN: Portfolio Planner Asset Allocation ProgramSM (Optional)1 : This program prohibits allocations to any investment options other than the model portfolio you choose below. Any allocations or transfers directly to any other investment option will automatically terminate your enrollment in the program. The Fixed Accumulation Feature or any of the Dollar Cost Averaging programs are available and may be used to dollar cost average into your model Portfolio. Investment Allocation (Please use whole percentages): Total must = 100%. Model Portfolio _____% Fixed Accumulation Feature _____%. 6 Month DCA Plus Program* _____% 12 Month DCA Plus Program* _____%. * If your allocation includes a DCA Plus Program, please provide Dollar Cost Averaging instructions below.
9 The destination of your DCA Plus program must be 100% to the Model Portfolio you select. Not available if deferral is elected within the California Senior Protection Program. Model Portfolio Selection Please select only one Model Portfolio below. Income 20061 Enhanced Income 20061 Growth and Income 20061. AllianceBernstein International Value 7% AllianceBernstein International Value 8% AllianceBernstein International Value 9%. AllianceBernstein Value 6% AllianceBernstein Value 6% AllianceBernstein Value 6%. Hartford Disciplined Equity 17% Fidelity VIP Equity-Income 5% Fidelity VIP Equity-Income 5%. Hartford High Yield 5% Hartford Disciplined Equity 22% Hartford Disciplined Equity 24%. Hartford Money Market 23% Hartford High Yield 5% Hartford International Opportunities 5%. Hartford Total Return Bond 16% Hartford International Opportunities 3% Hartford Total Return Bond 15%. Hartford Government Securities 15% Hartford Money Market 8% Hartford Government Securities 13%.
10 Oppenheimer Main Street Small Cap 3% Hartford Total Return Bond 16% Oppenheimer Capital Appreciation 3%. Putnam VT International Equity 4% Hartford Government Securities 15% Oppenheimer Main Street Small Cap 6%. Van Kampen Comstock 4% Oppenheimer Main Street Small Cap 4% Putnam VT International Equity 6%. Putnam VT International Equity 4% Putnam VT Small Cap Value 4%. Van Kampen Comstock 4% Van Kampen Comstock 4%. Growth 20061 Aggressive Growth 20061. AllianceBernstein International Value 10% AllianceBernstein International Value 12%. AllianceBernstein Value 6% AllianceBernstein Value 6%. Fidelity VIP Equity-Income 6% Fidelity VIP Equity-Income 6%. Fidelity VIP Growth 3% Fidelity VIP Growth 3%. Hartford Disciplined Equity 28% Hartford Disciplined Equity 30%. Hartford International Opportunities 6% Hartford International Opportunities 7% 1 Not available with the Director M Access . Hartford Total Return Bond 12% Oppenheimer Capital Appreciation 5%.
