exh_app.htm

		Sales Office Time Stamp
	INDIVIDUAL VARIABLE ANNUITY APPLICATION First Investors Life Insurance Company [110 Wall Street] [New York, New York 10005]	Sales Office Time Stamp

1a. Variable Annuity Options First Choice Variable Annuity ⁫ First Choice Bonus Annuity⁫	1b. Amount of Initial Purchase Payment $_________________________________
1c. IRA Yes ⁫ No ⁫ Regular ⁫ Transfer ⁫ Rollover ⁫ Beneficiary ⁫	1d. 1035 Exchange Yes ⁫ No ⁫
2. Proposed Owner Information
2a. Name of Proposed Owner __________________________________ _______________________________ __________________________________ First Middle Last Date of Birth: _______ ______ ______ Age Last Birthday: ________ Place of Birth: ________________ ________________ Month Day Year State Country Social Security Number: _____________________ Sex Male ⁫ Female ⁫ Marital Status Single⁫ Married ⁫ Home Address ____________________________________________________________________________________________ Street City State Zip Telephone Numbers ____________________________________________ __________________________________________ Home Work
2b. Name of Proposed Joint Owner __________________________________ ______________________________ __________________________________ First Middle Last Date of Birth: _______ ______ ______ Age Last Birthday: ________ Place of Birth: ________________ ________________ Month Day Year State Country Social Security Number: _____________________ Sex Male ⁫ Female ⁫ Marital Status Single⁫ Married ⁫ Home Address ____________________________________________________________________________________________ Street City State Zip Telephone Numbers __________________________________________ ___________________________________________ Home Work
3. Annuitant Designation
3a. Annuitant: Name of Annuitant ______________________________ ___________________________ ___________________________ First Middle Last Address_______________________________________________________________Date of Birth________________________

Relationship to Proposed Owner___________________ Social Security Number_________________ Telephone #______________
3b. Joint Annuitant: Name of Joint Annuitant__________________...._________________________________....________________________________ First Middle Last Address__________________________________________________________________Date of Birth________________________ Relationship to Proposed Owner____________________ Social Security Number_________________ Telephone #______________
4. Beneficiary Designation
4a. Primary Beneficiary(ies) This designation is: Revocable ⁫ Irrevocable ⁫ 1. _________________________________________________________________________________________________________ First Name MI Last Name Social Security # Relationship % Share or Tax ID# (Total must equal 100%) ___________________________________________________________________________________________________________ Address: City State Zip Telephone Number 2. _________________________________________________________________________________________________________ First Name MI Last Name Social Security # Relationship % Share or Tax ID# (Total must equal 100%) ___________________________________________________________________________________________________________ Address: City State Zip Telephone Number 4b. Contingent Beneficiary(ies) This designation is: Revocable ⁫ Irrevocable ⁫ 1. _________________________________________________________________________________________________________ First Name MI Last Name Social Security # Relationship % Share or Tax ID# (Total must equal 100%) ___________________________________________________________________________________________________________ Address: City State Zip Telephone Number 2. _________________________________________________________________________________________________________ First Name MI Last Name Social Security # Relationship % Share or Tax ID# (Total must equal 100%) ___________________________________________________________________________________________________________ Address: City State Zip Telephone Number

Suitability

A variable annuity is designed to achieve long-term financial objectives. It is not suitable as a vehicle for short-term savings due to the charges applicable to the Contract. You should not purchase this Contract if you believe you may need to surrender it during the surrender charge period.

Right to Examine Period and Initial Purchase Payment Investment

Once your Variable Annuity Contract is issued and delivered to you, you have a “Free Look” period to decide if you want to keep your Contract. Your Free Look period begins when you sign and date your Contract Delivery Receipt or if your Contract is mailed to you, the Certified Return Receipt from the Post Office. The portion of the initial net premium allocated to the subaccounts will be invested in the Cash Management Fund subaccount for a period of time equal to the “Free Look” period as indicated on the Contract’s cover. After the Free Look period expires, the Company will transfer the invested funds to the subaccounts you have selected. Premium allocated to the Fixed Account will be invested in the Fixed Account upon issuance of the Contract.

Contract Disclosures The subaccount selections below are consistent with the investment objectives indicated. I understand that these subaccount selections and transfer options will be relied upon by First Investors Life in regard to all Contract Transactions. These options may be changed after the date of this application only by providing First Investors Life with a written request and instruction to change. There shall be no Annuity Contract unless a Contract is issued based on this Application.
5. Proposed Owner’s Financial Information
5a. Financial Resources Liquid Net Worth $_______________________ Total Net Worth $________________________ Annual Income $_________________________ Marginal Tax Rate ______________________% 5b. Investment Experience Stocks o Bonds o Mutual Funds o Other o None o Variable Life Insurance o 5c. Risk Profile
______________% Conservative ______________% Moderate – ______________% Moderate –	Willing to accept some risk, but more interested in stability of principal than in larger return on investments. Willing to accept average risk of fluctuation of principal in exchange for the potential of larger long-term returns on investments. Willing to accept significant fluctuation of principal in exchange for the potential for significant long-term returns on investment.
5d. Investment Objectives (Prioritize 1-4) _________Growth _________Income _________Tax Reduction _________Other
6a. Do you, the Proposed Owner understand that in the Annuity Contract applied for: 6b. The amount of the Cash Value may increase or decrease depending upon the investment experience of the Subaccounts and the interest paid on the Fixed Account, if chosen? 6c. The Contract values reflect certain deductions and charges? 6d. The Contract may be subject to a Surrender Charge, upon full or partial Surrender?		Yes ð Yes ð Yes ð	No ð No ð No ð
7. Did you, the Proposed Owner receive a prospectus?		Yes ð	No ð
If “Yes” indicate the date of the prospectus. Date: ________________________

8. Purchase Payment Investment Options
Subaccount Allocations Select the Subaccounts and/or the Fixed Account and the percentage of the net purchase payment to be allocated to each.
	Subaccount [Cash Management Fund] [Equity Income Fund] [Fund for Income Fund] [Government Fund] [Growth and Income Fund] [International Fund] [Investment Grade Fund]	% Allocated ___________ ___________ ___________ ___________ ___________ ___________ ___________		Subaccount [Opportunity Fund] [Select Growth Fund] [Special Situations Fund] [Target Maturity 2015 Fund] [Total Return Fund] Fixed Account (maximum 50%) Total Allocation	% Allocated ___________ ___________ ___________ ___________ ___________ ___________ 100%
9. Accumulation Value Reallocation Options Only the Automated Subaccount Reallocation Option or the Systematic Transfer Option but not both may be in effect at the same time. The Fixed Account is not eligible for Automatic Reallocation.
9a. Automated Subaccount Reallocation Option Do you select the Automated Subaccount Reallocation Option feature of your Contract? Yes ð No ð If Yes, Automatic Reallocation will occur quarterly based on the Purchase Payment allocations selected for the Subaccounts.
9b. Systematic Transfer Option Do you select the Systematic Transfer Option? Yes ð No ð If “Yes” select the frequencyMonthly o Quarterly o Designate the Subaccounts to be used for the Transfer. The Fixed Account is not eligible for the Systematic Transfer Option.
	Transfer Amount ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________		From Subaaccount [Cash Management Fund] [Equity Income Fund] [Fund for Income Fund] [Government Fund] [Growth and Income Fund] [International Fund] [Investment Grade Fund] [Opportunity Fund] [Select Growth Fund] [Special Situation Fund] [Target Maturity 2015 Fund] [Total Return Fund]		To Subaccount ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________
Minimum Transfer Amount is $100 (Whole Dollar Amounts Only)

10. Annuity Payment Information
10a. Annuity Payout Benefit Options		10b. Annuity Payments to Begin
o Single Life Annuity o Joint and Two Thirds to Survivor	o Joint and Survivor Annuity o Joint and One-Half to Survivor	Age 65 Other		o o ___________________
o Single Life Annuity with Payments Guaranteed for o 10 Years o 20 Years		10c. Frequency of Payments
o Joint and Survivor Annuity with Payments Guaranteed for o 10 Years o 20 Years o Refund Life Annuity		Monthly Semi Annual	o o	Quarterly Annual	o o
10d. Payout Option: o Fixed o Variable o Combination Fixed ____% Variable ____% 10e. Assumed Interest Rate: o 0% o 3% o 5% (for variable annuity payment calculation)
11. Remarks ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ (Attach an Additional Sheet if Necessary)

Proposed Owner’s Acknowledgement

1.	Do you have an existing annuity contract(s) or life insurance policy(ies) currently in force or applied for?

Yes o No o

2.	Is the Annuity applied for intended to replace any other annuity contract(s) or life insurance policy(ies) currently in force?

Yes o No o

3.	Did you receive a prospectus?

Yes o No o If “Yes” indicate the date of the prospectus. Date: _____________

If you answer “Yes” to 1 and/or 2, please furnish company name(s) and contract and/or policy numbers in the “Remarks” section.

By signing below and submitting this Annuity Application, I acknowledge that:

●	My agent reviewed with me the benefits, fees, expenses, taxes and other information about the annuity I am applying for and I understand how the annuity contract fits within my overall financial needs and plan.

●	Based on that information and understanding, and to the best of my knowledge and belief, this annuity is appropriate and suitable for my investment time horizon, goals and objectives and financial situation and needs.

●	I hereby represent that my answers to the above questions to be true and correct to the best of my knowledge and belief. I understand that this application shall become part of any annuity contract issued by the Company.

Agent's Statement

To the best of your knowledge does any Proposed Owner have an existing annuity contract(s) or life insurance policy(ies)

currently in force or applied for?

Yes o No o

To the best of your knowledge is the annuity applied for intended to replace any other annuity contract(s) or life insurance

policy(ies) currently in force?

Yes o No o

3.	This purchase was: o Solicited o Unsolicited

By signing below, I certify that:

●	I discussed with the Proposed Owner the benefits, fees, taxes and other information about the annuity; and

●	I believe the annuity applied for is appropriate and suitable for the Proposed Owner.

Fraud Warning

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.

Dated at _______________________________________________ this _______day of ____________________, 2______

City & State day Month Year

Signature of Proposed Owner____________________________________________________________________________

Signature of Proposed Joint Owner (if any)_________________________________________________________________

Signature of Annuitant (if other than the Proposed Owner)_____________________________________________________

Signature of Joint Annuitant (if other than the Proposed Owner)_________________________________________________

Name of Licensed Agent________________________________________________________________________________

Signature of Licensed Agent_____________________________________________________________________________

Agent’s License Number: _______________________________________________________________________________

Manager’s Section: I believe that the purchase of this annuity is suitable, taking into consideration all of the factors cited above, as well as what is cited in Rules 2310 and 2821.

Name of Manager/Designee_________________________________________________________Date______________________

Signature of Manager/Designee______________________________________________________Date______________________