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Unallocated Fixed Contract Application, Acceptance, & New Business Agreement <br />American United Life Insurance Company@ Version 1.0 -- 04/2008 <br />P. O. Box <br />Indianapolis, Indiana 46206-0368 <br />Contract Number G80407 Contract Effective Date <br />Contract Suffix Number <br />Plan Sponsor's State of Domicile CA <br />The Proposed Contractholder identified below hereby applies to American United Life Insurance Company (AUL) for the Group <br />Annuity Contract Number identified above. This completed form must be approved by the AUL Corporate Office before a group <br />annuity contract will be issued. <br />Contract Type: <br />® Unallocated Fixed -Only (15FP) <br />Select Governmental or Non -Governmental Plan Sponsor (select only one): <br />® Governmental (non -registered) ❑ Private Sector (registered) <br />Select Plan Type (select only one): <br />❑ (1) 3121 or Special Pay 401(a) ❑ (3) 3121 or Special Pay or Employer -Sponsored 401(a)/403(b) ® (7) 3121 <br />457(b) ❑ (R) HRA Trust/VEBA ❑ (S) HSA ❑ (T) GASB 45 OPEB Trust/VEBA <br />Select Product Type (select only one): <br />❑ EO ®E1 ❑ R2 ❑ E013 ❑ E113 ❑ R213 <br />Select Business Type (select only one): <br />® Start-up ❑ Takeover <br />General Information <br />Proposed Contractholder: City of Pleasanton <br />Employer's Identification Number (EIN): 94-6000397 <br />Executive Contact: Nelson Fialho Phone # : 925-931-5050 Fax #: <br />Executive Contact's Address: P.O. Box 520, Pleasanton, CA <br />Executive Contact's Email Address: nfialho@ci.pleasanton.ca.us <br />Administrative Contact: Margaret Lyons Phone # : 925-931-5410 Fax # : 925-461-6855 <br />Administrative Contact's Address: P.O. Box 520, Pleasanton, CA <br />Administrative Contact's Email Address: mlyons@ci.pleasanton.ca.us <br />Producer Information <br />Primary Producer: Primary B/D: <br />Primary Producer Address: <br />Primary Producer Email Address: <br />Primary Phone: Primary Fax: <br />