Exhibit 4(a)Flexible Premium Variable Annuity • December 29th, 2000 • Variable Annuity 1 Series Account
Social Security Number Date of Birth Sex ____Female (If the Contract Owner is a ____Male Daytime Telephone ( ) trust, list the date(s) of birth for the beneficial owner(s)) ______________________________________________________________________________Flexible Premium Variable Annuity • January 31st, 2000 • Allianz Life Variable Account B
Social Security Number Date of Birth Sex ____Female (If the Contract Owner is a ____Male Daytime Telephone ( ) trust, list the date(s) of birth for the beneficial owner(s)) ______________________________________________________________________________Flexible Premium Variable Annuity • July 6th, 1999 • Allianz Life Variable Account B
Social Security Number Date of Birth Sex ____Female (If the owner is a trust, ____Male Daytime Telephone ( ) list the date(s) of birth for the beneficial owner(s)) ______________________________________________________________________________Flexible Premium Variable Annuity • July 1st, 1999 • Preferred Life Variable Account C
Social Security Number Date of Birth Sex ____Female (If the owner is a trust, ____Male Daytime Telephone ( ) list the date(s) of birth for the beneficial owner(s)) ______________________________________________________________________________Flexible Premium Variable Annuity • September 18th, 1998 • Allianz Life Variable Account B