EX-5.C2 4 dex5c2.txt EXHIBIT 5.C2 EXHIBIT (5)(c)(2) FORM OF INDIVIDUAL APPLICATION FOR THE SEPARATE ACCOUNT VA C ----------------------------------------------------------------------------------------------- Mail the application and a check to: Transamerica Life Insurance Company Attn: Variable Annuity Dept. Transamerica Life 4333 Edgewood Road N.E. Product: EXTRA ----------------------- Insurance Company Cedar Rapids, IA 52499-0001 Variable Annuity Application -----------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------- 1. OWNER INFORMATION (If no Annuitant is specified in #2, the Owner will be -------------------- the Annuitant.) MUST COMPLETE and SUBMIT the Trustee Certification Form if a Trust is named as the Owner or Beneficiary. First Name: ____________________________________________________________________ Last Name: _____________________________________________________________________ Address: _______________________________________________________________________ City, State: ___________________________________________________________________ Zip: ____________-____________ Telephone: ______________________________________ Date of Birth:___________________________________________ Sex: [_] Female SSN/TIN: ________________________________________________ [_] Male -------------------------------------------------------------------------------- 1b. JOINT OWNER(S) ------------------- First Name: ____________________________________________________________________ Last Name: _____________________________________________________________________ Address: _______________________________________________________________________ City, State: ___________________________________________________________________ Zip: ____________-____________ Telephone: ______________________________________ Date of Birth:___________________________________________ Sex: [_] Female SSN/TIN: ________________________________________________ [_] Male -------------------------------------------------------------------------------- 2. ANNUITANT Complete only if different from Owner. ------------- First Name: ____________________________________________________________________ Last Name: _____________________________________________________________________ Address: _______________________________________________________________________ City, State: ___________________________________________________________________ Zip: ____________-____________ Telephone: ______________________________________ Date of Birth:___________________________________________ Sex: [_] Female SSN/TIN: ________________________________________________ [_] Male -------------------------------------------------------------------------------- 3. BENEFICIARY(IES) DESIGNATION -------------------------------- Primary Contingent Name Relationship [_] [_] __________________________ _____________________ ______% [_] [_] __________________________ _____________________ ______% [_] [_] __________________________ _____________________ ______% -------------------------------------------------------------------------------- 4. TYPE OF ANNUITY ------------------- [_] Non-qualified Qualified Types: [_] IRA [_] Roth IRA [_] SEP/IRA [_] 403(b) [_] Keogh [_] Roth Conversion [_] Other ___________________________________________ IRA / SEP / ROTH IRA $ ________________ Contribution for tax year _______________ $ ________________ Trustee to Trustee Transfer $ ________________ Rollover from [_] IRA [_] 403(b) [_] Pension [_] Other __________________________________________ ROTH IRA Rollover _________________ Date first established or date of conversion $_________________ Portion previously taxed -------------------------------------------------------------------------------- 5. GUARANTEED MINIMUM DEATH BENEFITS ------------------------------------- Your selection cannot be changed after the policy has been issued. If no option is specified, the Return of Premium Death Benefit will apply. [_] Double Enhanced Death Benefit, available for issue through age 80. Daily M&E Risk Fee and Administrative Charge is 2.00% annually. [_] Return of Premium Death Benefit, available for issue through age 90. Daily M&E Risk Fee and Administrative Charge is 1.75% annually. -------------------------------------------------------------------------------- 6. AVAILABLE OPTIONS --------------------- Must complete this section. If no selection is made, the benefit will not apply. Managed Annuity Program: [_] Yes (Available at an additional cost, see prospectus) [_] No Additional Death Distribution: [_] Yes (Available at an additional cost, see prospectus) [_] No -------------------------------------------------------------------------------- 7. TELEPHONE TRANSFER AUTHORIZATION ------------------------------------ Please complete this section to authorize you and/or your Registered Representative to make transfer requests via our recorded telephone line or internet. (check one selection only): [_] Owner(s) only, or [_] Owner(s) and Owner's Registered Representative EXTRA2002-APP 01/02 8132112 01/02 EXTRA -------------------------------------------------------------------------------- 8. ALLOCATION OF PURCHASE PAYMENTS ----------------------------------- If Dollar Cost Averaging, Section 9 must be completed. Initial Purchase Payment $____________________ Make check payable to Transamerica Life Insurance Company. Dollar Cost Averaging Account _________ .0% Fixed Accounts: 1 Year Fixed Guarantee Period Option _________ .0% 3 Year Fixed Guarantee Period Option _________ .0% 5 Year Fixed Guarantee Period Option _________ .0% 7 Year Fixed Guarantee Period Option _________ .0% Subaccounts: Aggressive Asset Allocation _________ .0% AIM V.I. Basic Value Fund - Series II Shares _________ .0% AIM V.I. Capital Appreciation Fund - Series II Shares _________ .0% Alger Aggressive Growth _________ .0% Alliance Growth & Income Portfolio - Class B _________ .0% Alliance Premier Growth Portfolio - Class B _________ .0% American Century Income & Growth _________ .0% American Century International _________ .0% BlackRock Global Science & Technology _________ .0% BlackRock Mid Cap Growth _________ .0% Capital Guardian Global _________ .0% Capital Guardian U.S. Equity _________ .0% Capital Guardian Value _________ .0% Clarion Real Estate Securities _________ .0% Conservative Asset Allocation _________ .0% Dreyfus Small Cap Value _________ .0% Fidelity - VIP Equity-Income Portfolio - Service Class 2 _________ .0% Fidelity - VIP Growth Portfolio - Service Class 2 _________ .0% Fidelity - VIP Contrafund(R) Portfolio - Service Class 2 _________ .0% Fidelity - VIP Mid Cap Portfolio - Service Class 2 _________ .0% Fidelity - VIP Value Strategies Portfolio - Service Class 2 _________ .0% Gabelli Global Growth _________ .0% Great Companies - America(SM) _________ .0% Great Companies - Global/2/ _________ .0% Great Companies - Technology(SM) _________ .0% Janus Aspen - Aggressive Growth Portfolio - Service Shares _________ .0% Janus Aspen - Worldwide Growth Portfolio - Service Shares _________ .0% Janus Balanced (A/T) _________ .0% Janus Growth II (A/T) _________ .0% Jennison Growth _________ .0% J.P. Morgan Enhanced Index _________ .0% MFS High Yield _________ .0% MFS New Discovery Series - Service Class _________ .0% MFS Total Return Series - Service Class _________ .0% Moderate Asset Allocation _________ .0% Moderately Aggressive Asset Allocation _________ .0% PBHG/NWQ Value Select _________ .0% PBHG Mid Cap Growth _________ .0% PIMCO Total Return _________ .0% Salomon All Cap _________ .0% Transamerica Convertible Securities _________ .0% Transamerica Equity _________ .0% Transamerica Growth Opportunities _________ .0% Transamerica U.S. Government Securities _________ .0% T. Rowe Price Equity Income _________ .0% T. Rowe Price Growth Stock _________ .0% T. Rowe Price Small Cap _________ .0% Van Kampen Active International Allocation _________ .0% Van Kampen Asset Allocation _________ .0% Van Kampen Emerging Growth _________ .0% Van Kampen Money Market _________ .0% TOTAL VARIABLE AND FIXED 100% ------------------------------------------------------------------------------- 9. DOLLAR COST AVERAGING PROGRAM --------------------------------- If DCA is selected as an initial purchase payments allocation option under Section 8, please complete the following information to provide allocations in order to start the Dollar Cost Averaging Program. Special DCA Fixed Accounts: [_] Special 6-month DCA Fixed Account (when available) [_] Special 12-month DCA Fixed Account (when available) DCA Accounts: Specify account and frequency of transfer. [_] Money Market } {[_] Monthly (6-24) } { [_] Dreyfus U.S. Government Securities }-->{[_] Quarterly (4-8) [_] Traditional DCA } {_____# of Transfers TRANSFER TO: Aggressive Asset Allocation _________ .0% AIM V.I. Basic Value Fund - Series II Shares _________ .0% AIM V.I. Capital Appreciation Fund - Series II Shares _________ .0% Alger Aggressive Growth _________ .0% Alliance Growth & Income Portfolio - Class B _________ .0% Alliance Premier Growth Portfolio - Class B _________ .0% American Century Income & Growth _________ .0% American Century International _________ .0% BlackRock Global Science & Technology _________ .0% BlackRock Mid Cap Growth _________ .0% Capital Guardian Global _________ .0% Capital Guardian U.S. Equity _________ .0% Capital Guardian Value _________ .0% Clarion Real Estate Securities _________ .0% Conservative Asset Allocation _________ .0% Dreyfus Small Cap Value _________ .0% Fidelity - VIP Equity-Income Portfolio - Service Class 2 _________ .0% Fidelity - VIP Growth Portfolio - Service Class 2 _________ .0% Fidelity - VIP Contrafund(R) Portfolio - Service Class 2 _________ .0% Fidelity - VIP Mid Cap Portfolio - Service Class 2 _________ .0% Fidelity - VIP Value Strategies Portfolio - Service Class 2 _________ .0% Gabelli Global Growth _________ .0% Great Companies - America(SM) _________ .0% Great Companies - Global/2/ _________ .0% Great Companies - Technology(SM) _________ .0% Janus Aspen - Aggressive Growth Portfolio - Service Shares _________ .0% Janus Aspen - Worldwide Growth Portfolio - Service Shares _________ .0% Janus Balanced (A/T) _________ .0% Janus Growth II (A/T) _________ .0% Jennison Growth _________ .0% J.P. Morgan Enhanced Index _________ .0% MFS High Yield _________ .0% MFS New Discovery Series - Service Class _________ .0% MFS Total Return Series - Service Class _________ .0% Moderate Asset Allocation _________ .0% Moderately Aggressive Asset Allocation _________ .0% PBHG/NWQ Value Select _________ .0% PBHG Mid Cap Growth _________ .0% PIMCO Total Return _________ .0% Salomon All Cap _________ .0% Transamerica Convertible Securities _________ .0% Transamerica Equity _________ .0% Transamerica Growth Opportunities _________ .0% Transamerica U.S. Government Securities _________ .0% T. Rowe Price Equity Income _________ .0% T. Rowe Price Growth Stock _________ .0% T. Rowe Price Small Cap _________ .0% Van Kampen Active International Allocation _________ .0% Van Kampen Asset Allocation _________ .0% Van Kampen Emerging Growth _________ .0% Van Kampen Money Market _________ .0% TOTAL MUST = 100% EXTRA2002-APP 01/02 (2) -------------------------------------------------------------------------------- 10. ASSET REBALANCING --------------------------------- I elect to rebalance the variable subaccounts according to my Allocation of Purchase Payments using the frequency indicated below (Not available with DCA). If you would like to rebalance to a mix other than the indicated Allocation of Purchase Payments, please complete the Optional Programs Form. [_] Quarterly [_] Semi-Annually [_] Annually -------------------------------------------------------------------------------- 11. SIGNATURE(S) OF AUTHORIZATION ACCEPTANCE --------------------------------------------- . Unless I have notified the Company of a community or marital property interest in this contract, the Company will rely on good faith belief that no such interest exists and will assume no responsibility for inquiry. . To the best of my knowledge and belief, my answers to the questions on this application are correct and true. . I am in receipt of a current prospectus for this variable annuity. . This application is subject to acceptance by Transamerica Life Insurance Company. If this application is rejected for any reason, Transamerica Life Insurance Company will be liable only for return of purchase payment paid. [_] Check here if you want to be sent a copy of "Statement of Additional Information". Will this annuity replace or change any existing annuity or life insurance? [_] No [_] Yes (If yes, complete the following) Company: _______________________________________________________________________ Policy No.: ____________________________________________________________________ I HAVE REVIEWED MY EXISTING ANNUITY COVERAGE AND FIND THIS COVERAGE SUITABLE FOR MY NEEDS. ------------------------------------------------------------ For applicants in all states except Connecticut, New Jersey, Pennsylvania and Washington When funds are allocated to the Fixed Options Guarantee Periods, policy values under the policy may increase or decrease in accordance with an Excess Interest Adjustment prior to the end of the Guaranteed Period. ------------------------------------------------------------ Account values when allocated to any of the Variable Options are not guaranteed as to fixed dollar amount. Signed at: ___________________________________________________________________ City State Date Owner(s) Signature: __________________________________________________________ Joint Owner(s) Signature: ____________________________________________________ Annuitant Signature: (if not Owner) __________________________________________ -------------------------------------------------------------------------------- 12. AGENT INFORMATION ---------------------- Do you have any reason to believe the annuity applied for will replace or change any existing annuity or life insurance? [_] No [_] Yes I HAVE REVIEWED THE APPLICANT'S EXISTING ANNUITY COVERAGE AND FIND THIS COVERAGE IS SUITABLE FOR HIS/HER NEEDS. Registered Rep/Licensed Agent:__________________________________________________ Please print First Name:________________________________________________________ Please print Last Name:_________________________________________________________ Signature:______________________________________________________________________ Rep Phone #:____________________________________________________________________ SSN/TIN:________________________________________________________________________ Rep. License #:_________________________________________________________________ Firm Name:______________________________________________________________________ Firm Address:___________________________________________________________________ For Registered Representative Use Only - Contact your home office for program information. [_] Option A [_] Option B [_] Option C [_] Option D (Once selected, program cannot be changed) -------------------------------------------------------------------------------- For applicants in Louisiana, Montana and New Hampshire -------------------------------------------------------------------------------- Applicant: Do you have any existing policies or contracts? [_] No [_] Yes (If yes, you must complete and submit with the application the "Important Notice Replacement of Life Insurance or Annuities".) 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 fines and confinement in prison. Agent: Did the agent/registered representative present and leave the applicant insurer-approved sales material? [_] No [_] Yes Clear Form EXTRA2002-APP 01/02 (3) -------------------------------------------------------------------------------- For applicants in Florida -------------------------------------------------------------------------------- Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. -------------------------------------------------------------------------------- For applicants in New Jersey -------------------------------------------------------------------------------- Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. -------------------------------------------------------------------------------- For applicants in Pennsylvania -------------------------------------------------------------------------------- Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects a person to criminal and civil penalties. EXTRA2002-APP 01/02 (4)