EX-5.D 3 dex5d.txt EXHIBIT 5.D EXHIBIT (5)(d) FORM OF APPLICATION
[LOGO TRANSAMERICA] LANDMARK VARIABLE ANNUITY APPLICATION Mail the application and a check to: Transamerica Life Insurance Company Attn: Variable Annuity Dept. Service Office: P.O. Box 3183, Cedar Rapids, IA 52406-3183 Overnight Mailing Address: 4333 Edgewood Rd. NE, Cedar Rapids, IA 52499 ------------------------------------ -------------------------------- 1. TYPE OF ANNUITY (SOURCE OF FUNDS) 4. BENEFICIARY(IES) DESIGNATION ------------------------------------ -------------------------------- Initial purchase payment $ ___________________ Name Relationship o Primary o Non qualified o New Money o 1035 Exchange _________________________________% o Contingent o Qualified o New Money o Rollover o Transfer Name Relationship o Primary Qualified Type: o IRA o Roth IRA o SEP/IRA o 403(b) _________________________________% o Contingent o Keogh o Roth Conversion o Other ______ IRA/SEP/ROTH IRA Name Relationship o Primary $ _________ Contribution for tax year ____ $ _________ Trustee to Trustee Transfer _________________________________% o Contingent $ _________ Rollover from o IRA o 403(b) o Pension o Other _______ Name Relationship o Primary ROTH IRA Rollover ____________ Date first established or date of _________________________________% o Contingent conversion $ ____________ Portion previously taxed Name Relationship o Primary _________________________________% o Contingent ------------------------------- ---------------------------- 2(a). PRIMARY OWNER INFORMATION 5. GUARANTEED DEATH BENEFITS ------------------------------- ---------------------------- If no Annuitant is specified in #3, the Owner will be the Annuitant. If a Trust If no option is specified, the Return of Premium Death Benefit is named as Owner or Beneficiary, will apply. Your selection cannot be changed after the additional paperwork will be required. policy has been issued. First Name:_____________________________________ Last Name: _____________________________________ o Return of Premium Death Benefit, available for issue through Address: _____________________________________ age 90. City, State:____________________________________ Daily M&E Risk Fee and Administrative Charge is 1.30% annually. Zip: ________-_________ Telephone:______________ o Annual Step-Up Death Benefit, available for issue through age Email Address (optional):_______________________ 75. Daily M&E Risk Fee and Administrative Charge is 1.5% annually. Date of Birth: ________________ Sex: o Female o Male o Double Enhanced Death Benefit, available for issue through age 70. SSN/TIN: ______________________ Citizenship: o U.S. o Other Daily M&E Risk Fee and Administrative Charge is 1.80% annually. --------------------------------------- ----------------------------- 2(b). JOINT OWNER INFORMATION (Optional) 6. OTHER AVAILABLE RIDERS ---------------------------------------- ----------------------------- First Name:_____________________________________ If no selection is made, the benefit will not apply. Last Name: _____________________________________ Address: _____________________________________ Additional Death Distribution (earnings enhancement): City, State:____________________________________ Zip: ________-_________ Telephone:______________ o Yes (Available at an additional cost, see prospectus) Email Address (optional):_______________________ o No Date of Birth: ________________ Sex: o Female o Male SSN/TIN: ______________________ Citizenship: o U.S. o Other Liquidity Rider: ------------- o Yes (Available at an additional cost, see prospectus) 3. ANNUITANT o No ------------- Complete only if different from Primary Owner. ----------------------------------- 7. TELEPHONE TRANSFER AUTHORIZATION First Name:_____________________________________ ----------------------------------- Last Name: _____________________________________ Address: _____________________________________ Please complete this section to authorize you and/or your Registered City, State:____________________________________ Representative to make transfer requests via our recorded telephone Zip: ________-_________ Telephone:______________ line or internet. (check one selection only): Email Address (optional):_______________________ o Owner(s) only, or o Owner(s) and Owner's Registered Date of Birth: ________________ Sex: o Female o Male Representative SSN: ______________________ Citizenship: o U.S. o Other
VA-APP 05/03
----------------------------------------------------------------------------------------------------------------------- 8. PORTFOLIO INVESTMENT STRATEGY ----------------------------------------------------------------------------------------------------------------------- o Lump Sum o Combined: Lump Sum and DCA Program (must total 100%) I elect to allocate 100% of my contributions I elect to allocate as follows: according to percentage listed in Section 10 _______________% as a lump-sum contributions according to "Lump Sum Allocation Section". percentages listed in Section 10 "Lump Sum Allocation o Dollar Cost Averaging (DCA) Program Section". I elect to allocate 100% of my contributions _______________% in the DCA Account and transferred according to percentage listed in Section 11 according to percentages listed in Section 11 "DCA DCA "Transfer Allocation Section". Transfer Allocation Section". ------------------------------------------------------------------------------------------------------------------------ 9. DCA TRANSFER STRATEGY ------------------------------------------------------------------------------------------------------------------------- DCA Strategy (There is a $500 minimum transfer amount for the DCA program.) Transfer from: (Select 1 of the following) o 1. DCA Fixed Account*: o 2. Money Market Account: o 6 Mo. o 12 Mo. o 18 Mo. o 24 Mo. o 6 Mo. o 12 Mo. o 18 Mo. o 24 Mo. o Other: _____________________________ o Other: ______________________________ (Specify period and frequency) (Specify period and frequency) Complete Section 11 for DCA transfer allocation. o 3. Transamerica US Government Securities * Washington and Massachusetts residents, DCA o 6 Mo. o 12 Mo. o 18 Mo. o 24 Mo. cannot exceed twelve months or four quarters. o Other: ______________________________ (Specify period and frequency) ----------------------- 10. LUMP SUM ALLOCATION ----------------------- Fixed Accounts: _________ .0% 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* Subaccounts: _________ .0% Asset Allocation - Conservative Portfolio - Service Class _________ .0% Asset Allocation - Growth Portfolio - Service Class _________ .0% Asset Allocation - Moderate Portfolio - Service Class _________ .0% Asset Allocation - Moderate Growth Portfolio - Service Class _________ .0% AIM V.I. Basic Value Fund - Series II _________ .0% AIM V.I. Capital Appreciation Fund - Series II _________ .0% Alger Aggressive Growth - Service Class _________ .0% Alliance Growth & Income Portfolio - Class B _________ .0% Alliance Premier Growth Portfolio - Class B _________ .0% American Century Income & Growth - Service Class _________ .0% American Century International - Service Class _________ .0% BlackRock Global Science & Technology Opportunities - Service Class _________ .0% BlackRock Mid Cap Growth - Service Class _________ .0% Capital Guardian Global - Service Class _________ .0% Capital Guardian U.S. Equity - Service Class _________ .0% Capital Guardian Value - Service Class _________ .0% Clarion Real Estate Securities - Service Class _________ .0% Fidelity - VIP Contrafund(R) Portfolio - Service Class 2 _________ .0% Fidelity - VIP Equity-Income Portfolio - Service Class 2 _________ .0% Fidelity - VIP Growth Portfolio - Service Class 2 _________ .0% Fidelity - VIP Mid Cap Portfolio - Service Class 2 _________ .0% Fidelity - VIP Value Strategies Portfolio -Service Class 2 _________ .0% Great Companies - America\SM\ - Service Class _________ .0% Great Companies - Global\2\ - Service Class _________ .0% Great Companies - Technology\SM\ - Service Class _________ .0% Janus Aspen - Mid Cap Growth Portfolio - Service Shares _________ .0% Janus Aspen - Worldwide Growth Portfolio - Service Shares _________ .0% Janus Balanced (A/T) - Service Class _________ .0% Janus Growth (A/T) - Service Class _________ .0% Jennison Growth - Service Class _________ .0% J.P. Morgan Enhanced Index - Service Class _________ .0% MFS High Yield - Service Class _________ .0% MFS New Discovery Series - Service Class _________ .0% MFS Total Return Series - Service Class _________ .0% PBHG/NWQ Value Select - Service Class _________ .0% PBHG Mid Cap Growth - Service Class _________ .0% PIMCO Total Return - Service Class _________ .0% Salomon All Cap - Service Class _________ .0% Transamerica Convertible Securities - Service Class _________ .0% Transamerica Equity - Service Class _________ .0% Transamerica Growth Opportunities - Service Class _________ .0% Transamerica Money Market - Service Class _________ .0% Transamerica U.S. Government Securities - Service Class _________ .0% T. Rowe Price Equity Income - Service Class _________ .0% T. Rowe Price Growth Stock - Service Class _________ .0% T. Rowe Price Small Cap - Service Class _________ .0% Van Kampen Active International Allocation - Service Class _________ .0% Van Kampen Asset Allocation - Service Class _________ .0% Van Kampen Emerging Growth - Service Class ---------------------------- 11. DCA TRANSFER ALLOCATION --------------------------- Transfer To: _________ .0% Asset Allocation - Conservative Portfolio - Service Class _________ .0% Asset Allocation - Growth Portfolio - Service Class _________ .0% Asset Allocation - Moderate Portfolio - Service Class _________ .0% Asset Allocation - Moderate Growth Portfolio - Service Class _________ .0% AIM V.I. Basic Value Fund - Series II _________ .0% AIM V.I. Capital Appreciation Fund - Series II _________ .0% Alger Aggressive Growth - Service Class _________ .0% Alliance Growth & Income Portfolio - Class B _________ .0% Alliance Premier Growth Portfolio - Class B _________ .0% American Century Income & Growth - Service Class _________ .0% American Century International - Service Class _________ .0% BlackRock Global Science & Technology Opportunities - Service Class _________ .0% BlackRock Mid Cap Growth - Service Class _________ .0% Capital Guardian Global - Service Class _________ .0% Capital Guardian U.S. Equity - Service Class _________ .0% Capital Guardian Value - Service Class _________ .0% Clarion Real Estate Securities - Service Class _________ .0% Fidelity - VIP Contrafund(R) Portfolio - Service Class 2 _________ .0% Fidelity - VIP Equity-Income Portfolio - Service Class 2 _________ .0% Fidelity - VIP Growth Portfolio - Service Class 2 _________ .0% Fidelity - VIP Mid Cap Portfolio - Service Class 2 _________ .0% Fidelity - VIP Value Strategies Portfolio -Service Class 2 _________ .0% Great Companies - America\SM\ - Service Class _________ .0% Great Companies - Global\2\ - Service Class _________ .0% Great Companies - Technology\SM\ - Service Class _________ .0% Janus Aspen - Mid Cap Growth Portfolio - Service Shares _________ .0% Janus Aspen - Worldwide Growth Portfolio - Service Shares _________ .0% Janus Balanced (A/T) - Service Class _________ .0% Janus Growth (A/T) - Service Class _________ .0% Jennison Growth - Service Class _________ .0% J.P. Morgan Enhanced Index - Service Class _________ .0% MFS High Yield - Service Class _________ .0% MFS New Discovery Series - Service Class _________ .0% MFS Total Return Series - Service Class _________ .0% PBHG/NWQ Value Select - Service Class _________ .0% PBHG Mid Cap Growth - Service Class _________ .0% PIMCO Total Return - Service Class _________ .0% Salomon All Cap - Service Class _________ .0% Transamerica Convertible Securities - Service Class _________ .0% Transamerica Equity - Service Class _________ .0% Transamerica Growth Opportunities - Service Class _________ .0% Transamerica Money Market - Service Class _________ .0% Transamerica U.S. Government Securities - Service Class _________ .0% T. Rowe Price Equity Income - Service Class _________ .0% T. Rowe Price Growth Stock - Service Class _________ .0% T. Rowe Price Small Cap - Service Class _________ .0% Van Kampen Active International Allocation - Service Class _________ .0% Van Kampen Asset Allocation - Service Class _________ .0% Van Kampen Emerging Growth - Service Class
*The following states only allow the 1 year Guaranteed Period Option: CT, FL, NJ, PA, VT, VA, WA No Guaranteed Period Options are allowed in: MA and OR VA-APP 05/03
----------------------- ---------------------- 12. ASSET REBALANCING 14. AGENT INFORMATION ----------------------- ---------------------- I elect to rebalance the variable Do you have any reason to believe the annuity subaccounts according to my lump applied for will replace or change any existing sum allocation using the frequency annuity or life insurance? indicated below. o No o Yes Does not include Fixed Accounts and not available with DCA. I HAVE REVIEWED THE APPLICANT'S EXISTING ANNUITY COVERAGE AND FIND THIS COVERAGE IS SUITABLE FOR If you would like to rebalance to a HIS/HER NEEDS. mix other than the indicated Allocation of Purchase Payments, # 1: Registered Rep/Licensed Agent please complete the Optional Programs Form. Print First Name:___________________________ Last Name:__________________________________ o Monthly o Quarterly o Semi-Annually o Annually Signature:X_________________________________ Rep Phone #:________________________________ -------------------------------------------- 13. SIGNATURE(S) OF AUTHORIZATION ACCEPTANCE Email Address (Optional):___________________ -------------------------------------------- o Check here if you want to be sent a copy of SSN/TIN:____________________________________ "Statement of Additional Information." Florida Agent License # (FL only):__________ Will this annuity replace or change any existing annuity or life insurance? o No o Yes (If yes, #2: Registered Rep/Licensed Agent complete the following) Print First Name:___________________________ Company:___________________________ Policy No.:________________________ Last Name:__________________________________ Signature:X_________________________________ o Unless I have notified the Company of a community or marital property interest in Rep Phone #:________________________________ this contract, the Company will rely on good faith belief that no such interest exists and Email Address (Optional):___________________ will assume no responsibility for inquiry. SSN/TIN:____________________________________ o To the best of my knowledge and belief, my statements and answers to the questions on Florida Agent License # (FL only):__________ this application are correct and true. Firm Name:__________________________________ o I am in receipt of a current prospectus for this variable annuity. Firm Address:_______________________________ o This application is subject to acceptance by For Registered Representative Use Only-Contact Transamerica Life Insurance Company. If this your home office for program information. application is rejected for any reason, Transamerica Life Insurance Company will be o Double Enhanced Death Benefit (only option for benefit) liable only for return of purchase payment o Option A o Option B o Option C paid. (Once selected, program cannot be changed) o Florida Residents-Any person who knowingly ------------------------ and with intent to injure, defraud, or deceive REPLACEMENT INFORMATION any insurer files a statement of claim or an ----------------------- application containing any false, incomplete, or misleading information is guilty of a For applicants in Colorado, Hawaii, Iowa, Louisiana, felony of the third degree. Maryland, Mississippi, Montana, New Hampshire, North Carolina, Vermont o Account values when allocated to any of the subaccounts in Section 10 are not guaranteed Applicant: as to fixed dollar amount. Do you have any existing policies or contracts? o No o Yes o For residents in all states except CT, MN, (If Yes, you must complete and submit with the application the PA, VT, VA, WA When funds are allocated to "Important Notice Replacement of Life Insurance or Annuities.") the Fixed Accounts in Section 10, policy values may increase or decrease in accordance Agent: with an Excess Interest Adjustment prior to the end of the Guaranteed Period. Did the agent/registered representative present and leave the applicant insurer-approved sales material? o No o Yes I HAVE REVIEWED MY EXISTING ANNUITY COVERAGE AND FIND THIS COVERAGE SUITABLE FOR MY NEEDS. Signed at:____________________________________ City State Date Owner(s) Signature: X_________________________ Joint Owner(s) Signature: X___________________ Annuitant Signature: (if not Owner) X_________
VA-APP 05/03
----------------------- ----------------------------- For Applicants in AZ For Applicants in KY, OH, OK ----------------------- ----------------------------- Upon your written request, the Company is Any person who knowingly and with intent to required to provide, within a reasonable defraud any insurance company or other person time, reasonable factual information files an application for insurance or concerning the benefits and provisions of the statement of claim containing any materially contract to you. If for some reason you are false information or conceals for the purpose not satisfied with the contract, you may of misleading, information concerning any return it within twenty days after it is fact material thereto commits a fraudulent delivered and receive a refund equal to the insurance act, which is a crime. premiums paid, including any policy or contract fees or other charges, less the amounts allocated to any separate accounts ---------------------- under the policy or contract, plus the value For Applicants in LA of any separate accounts under the policy or ----------------------- contract on the date the returned policy is received by the insurer. Any person who knowingly presents a false or fraudulent claim for payment of a loss or Annuity Commencement benefit or knowingly presents false Date:_____________________Recommended information in an application for insurance annuitant age 70 1/2 for qualified. is guilty of a crime and may be subject to fines and confinement in prison. ----------------------------- -------------------- For Applicants in AR, NM, PA For Applicants in ME ----------------------------- -------------------- Any person who knowingly and with intent to Any person who, with the intent to defraud or defraud any insurance company or other person knowing that he is facilitating a fraud files an application for insurance or against an insurer, submits an application or statement of claim containing any materially files a claim containing a false or deceptive false information or conceals for the purpose statement may have violated state law. of misleading, information concerning any fact material thereto commits a fraudulent -------------------- insurance act, which is a crime and subjects For Applicants in NJ a person to criminal and civil penalties. -------------------- -------------------- Any person who includes any false or misleading For Applicants in CO information on an application for an insurance -------------------- policy is subject to criminal and civil penalties. It is unlawful to knowingly provide false, --------------------- incomplete, or misleading facts or For Applicants in VA information to an insurance company for the --------------------- purpose of defrauding or attempting to defraud the company. Penalties may include Any person who, which the intent to defraud or knowing imprisonment, fines, and denial of insurance, that he is facilitating a fraud against an insurer, submits and civil damages. Any insurance company or an application or files a claim containing a false or deceptive agent or an insurance company who knowingly statement may have violated state law. This plan is intended to provides false, incomplete, or misleading qualify under the Internal Revenue Code for tax favored status. facts or information to the policyholder or Language contained in this policy referring to Federal tax statutes claimant for the purpose of defrauding or or rules is informational and instructional and this language is not attempting to defraud the policyholder or subject to approval for delivery. Your qualifying status is the claimant with regard to a settlement or award controlling factor as to whether your funds will receive tax favored payable from insurance proceeds shall be treatment rather than the insurance contract. Please ask your tax reported to the Colorado Division of advisor if you have any questions as to whether or not you qualify. Insurance within the Department of Regulatory Agencies. ------------------------- For Applicants in DC, TN ------------------------- It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
VA-APP 05/03