EX-99 2 nv41732008.txt APPLICATION EX-.5.k PERSPECTIVE II(R) (03/08) JACKSON(SM) FIXED AND VARIABLE ANNUITY NATIONAL LIFE INSURANCE COMPANY APPLICATION (VA220NY) OF NEW YORK See page 4 for mailing address. Home Office: Purchase, NY 10577 WWW.JNLNY.COM USE DARK INK ONLY - ALL PAGES MUST BE COMPLETED FOR "GOOD ORDER"
------------------------------------------------------------------------------- External Account No. (if applicable) Trade No. (if applicable) ------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------ REGISTRATION INFORMATION ------------------------------------------------------------------------------------------------------------------------------------ OWNER'S NAME (FIRST) (MIDDLE) (LAST) Date of Birth (mm/dd/yyyy) __ SSN __ TIN (include dashes) ------------------------------------------------------------------------------------------------------------------------------------ OWNER'S NAME (IF OWNED BY A NON-NATURAL ENTITY) ------------------------------------------------------------------------------------------------------------------------------------ Home Address (Physical Address Required) CITY STATE ZIP ------------------------------------------------------------------------------------------------------------------------------------ Mailing Address (if different from Home Address) CITY STATE ZIP ------------------------------------------------------------------------------------------------------------------------------------ Age Sex U.S. Citizen Phone No. (include area code) E-Mail Address Broker/Dealer Account Number __ M __F __ Yes __ No ------------------------------------------------------------------------------------------------------------------------------------ JOINT OWNER'S NAME (Proceeds will be distributed in accordance with the Contract on the first death of either Owner. ------------------------------------------------------------------------------------------------------------------------------------ (FIRST) (MIDDLE) (LAST) __ SSN __ TIN (include dashes) ------------------------------------------------------------------------------------------------------------------------------------ Home Address (Physical Address Required) CITY STATE ZIP Relationship to Owner (Check One) ___ Spouse ___ Other _________________ ------------------------------------------------------------------------------------------------------------------------------------ Date of Birth (mm/dd/yyyy) Age Sex U.S. Citizen Phone No. (include area code) E-Mail Address __ M __F __ Yes __ No ------------------------------------------------------------------------------------------------------------------------------------ ANNUITANT'S NAME (if other than Owner) (FIRST) (MIDDLE) (LAST) __ SSN __ TIN (include dashes) ------------------------------------------------------------------------------------------------------------------------------------ Home Address (number and street) CITY STATE ZIP Relationship to Owner (Check One) ___ Spouse ___ Other _________________ ------------------------------------------------------------------------------------------------------------------------------------ Date of Birth (mm/dd/yyyy) Age Sex U.S. Citizen Phone No. (include area code) E-Mail Address __ M __F __ Yes __ No ------------------------------------------------------------------------------------------------------------------------------------ JOINT ANNUITANT'S NAME (if other than Joint Owner) (FIRST) (MIDDLE) (LAST) __ SSN __ TIN (include dashes) ------------------------------------------------------------------------------------------------------------------------------------ Home Address (number and street) CITY STATE ZIP Relationship to Owner (Check One) ___ Spouse ___ Other _________________ ------------------------------------------------------------------------------------------------------------------------------------ Date of Birth (mm/dd/yyyy) Age Sex U.S. Citizen Phone No. (include area code) __ M __F __ Yes __ No ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ BENEFICIARY DESIGNATION ------------------------------------------------------------------------------------------------------------------------------------ Percentages must equal 100% for each beneficiary type. For additional beneficiaries, please attach a separate sheet, signed and dated by the Owner, which includes names, percentages, and other required information. ------------------------------------------------------------------------------------------------------------------------------------ Name __ SSN __ TIN (include dashes) Percentage (%) Primary ---------------------------------------------------------------------------------------------------------------------- Relationship to Owner (Check One) Date of Birth (mm/dd/yyyy) Address (number and street) City, State, ZIP ___ Spouse ___ Other _________________ ------------------------------------------------------------------------------------------------------------------------------------ Name __ SSN __ TIN (include dashes) Percentage (%) __ Primary __ Contingent ---------------------------------------------------------------------------------------------------------------------- Relationship to Owner Address (number and street) City, State, ZIP ------------------------------------------------------------------------------------------------------------------------------------ Name __ SSN __ TIN (include dashes) Percentage (%) __ Primary __ Contingent ---------------------------------------------------------------------------------------------------------------------- Relationship to Owner Address (number and street) City, State, ZIP ------------------------------------------------------------------------------------------------------------------------------------ Name SSN/TIN (include dashes) Percentage (%) __ Primary __ Contingent ---------------------------------------------------------------------------------------------------------------------- Relationship to Owner Address (number and street) City, State, ZIP NVDA 220 04/08 NV4173 03/08 ------------------------------------------------------------------------------------------------------------------------------------ ANNUITY TYPE ------------------------------------------------------------------------------------------------------------------------------------ __ Non-Tax Qualified __ IRA - SEP __ IRA - Individual* __ 401(k) Qualified Savings Plan __ IRA - Custodial __ IRA - Roth* __ HR-10 (Keogh) Plan __ Other __________________ *Tax Contribution Years and Amounts: __ 403(b) TSA (Direct Transfer Only) Year:______ $____________ Year:______ $____________ ------------------------------------------------------------------------------------------------------------------------------------ TRANSFER INFORMATION ------------------------------------------------------------------------------------------------------------------------------------ __ IRC 1035 Exchange Transfer request submitted directly to another institution? __ Yes __ No __ Direct Transfer If yes, complete the following: __ Direct Rollover Anticipated Amount: $_________________ __ Non-Direct Rollover Anticipated Date of Receipt (mm/dd/yyyy): _________________ Institution releasing funds: __________________________________ Account Number: _________________________________________ ------------------------------------------------------------------------------------------------------------------------------------ INITIAL PREMIUM INCOME DATE ------------------------------------------------------------------------------------------------------------------------------------ Amount of premium with application: $__________________________ PLEASE SPECIFY DATE (mm/dd/yyyy): _________________ MAKE ALL CHECKS PAYABLE TO JACKSON NATIONAL LIFE INSURANCE COMPANY OF NEW If an Income Date is not specified, the Company YORK(R) will default to the Latest Income Date as shown in the contract. ------------------------------------------------------------------------------------------------------------------------------------ OPTIONAL DEATH BENEFIT - ONCE SELECTED, OPTIONAL BENEFITS CANNOT BE CHANGED. ------------------------------------------------------------------------------------------------------------------------------------ If the Optional Death Benefit is not selected, your beneficiary(ies) will receive the standard death benefit. Please see the prospectus for details. ___ Highest Anniversary Value Death Benefit ADDITIONAL CHARGES WILL APPLY. PLEASE SEE THE PROSPECTUS FOR DETAILS. ------------------------------------------------------------------------------------------------------------------------------------ OPTIONAL BENEFITS - ONCE SELECTED, OPTIONAL BENEFITS CANNOT BE CHANGED. ------------------------------------------------------------------------------------------------------------------------------------ A. CONTRACT ENHANCEMENT OPTIONS /1/ GUARANTEED LIVING BENEFIT OPTIONS (CONTINUED) (MAY SELECT ONLY ONE) Guaranteed Minimum Withdrawal Benefit (GMWB) Options /5/ ___ 2% of first-year premium /2/ ___ SafeGuard Max(SM) ___ 3% of first-year premium /2/ (GMWB with 5-Year Step-Up) ___ 4% of first-year premium /2/ ___ AutoGuard 5(SM) (5% GMWB with Annual Step-Up) B. WITHDRAWAL OPTIONS ___ AutoGuard 6(SM) ___ 20% Additional Withdrawal Benefit /3/ (6% GMWB with Annual Step-Up) ___ 5-Year Withdrawal Charge Schedule ___ MarketGuard 5(SM) (5% GMWB) C. GUARANTEED LIVING BENEFIT OPTIONS (MAY SELECT ___ LifeGuard Freedom(SM) ONLY ONE GMIB OR GMWB) (For Life GMWB with Bonus and Annual Step-Up) Guaranteed Minimum Income Benefit Option /4/ ___ LifeGuard Freedom with Joint Option(SM) /6//7/ ___ FutureGuard(SM) (Joint For Life GMWB with Bonus and Annual Step-Up) ADDITIONAL CHARGES WILL APPLY. PLEASE SEE THE PROSPECTUS FOR DETAILS. /1/ Please complete the Important Disclosure Regarding the Contract Enhancement. /2/ Selection of the 2%, 3%, or 4% Contract Enhancement option will prohibit allocation or transfer of any premium to the 3, 5, or 7-Year Fixed Account Options during the Recapture period of that selected option. /3/ May not be selected in combination with the 3% or 4% Contract Enhancement. /4/ The GMIB may not be appropriate for Owners who will be subject to any minimum distribution requirements under an IRA or other qualified plan prior to the expiration of 10 contract years. Please consult a tax advisor on this and other matters of selecting income options. /5/ A GMWB may not be appropriate for the Owners who have as a primary objective taking maximum advantage of the tax deferral that is available to them under an annuity Contract. These endorsements may also have limited usefulness in connection with tax-qualified contracts in relation to required minimum distributions imposed by the IRS. Some withdrawals necessary to satisfy required minimum distributions may prematurely deteriorate the benefits provided by a GMWB. When purchasing a tax-qualified contract, special consideration should be given to whether or not the purchase of GMWB is appropriate for the Owner's situation, including required minimum distributions. Please consult a tax advisor on this and other matters of selecting income options. /6/ For Non-Qualified plans, spousal joint ownership required. Please ensure the Joint Owner section on Page 1 (including the "Relationship to Owner" box) is properly completed. /7/ For Qualified plans, 100% spousal primary beneficiary designation required. Please ensure the Primary Beneficiary section on Page 1 (including the "Relationship to Owner" box) is properly completed. Not available on Custodial Accounts. Page 2 of 5 NVDA 220 04/08 NV4173 03/08 ------------------------------------------------------------------------------------------------------------------------------------ TOTAL NUMBER OF ALLOCATIONS MAY NOT EXCEED 18 PREMIUM ALLOCATION WHOLE PERCENTAGES ONLY * TOTAL ALLOCATION MUST EQUAL 100% ------------------------------------------------------------------------------------------------------------------------------------ NUMBER JNL /AIM PORTFOLIOS NUMBER JNL/MELLON PORTFOLIOS (CONTINUED) 113 ___% International Growth 223 ___% Value Line(R) 30 196 ___% Large Cap Growth 191 ___% Communications Sector 206 ___% Real Estate 185 ___% Consumer Brands Sector 195 ___% Small Cap Growth 189 ___% Financial Sector JNL/CAPITAL GUARDIAN PORTFOLIOS 188 ___% Healthcare Sector 150 ___% Global Balanced 190 ___% Oil & Gas Sector 103 ___% Global Diversified Research 187 ___% Technology Sector 250 ___% International Small Cap JNL/OPPENHEIMER PORTFOLIOS 102 ___% U.S. Growth Equity 173 ___% Global Growth JNL/CREDIT SUISSE PORTFOLIOS JNL/PAM PORTFOLIOS 066 ___% Global Natural Resources 272 ___% Asia ex-Japan 068 ___% Long/Short 273 ___% China-India JNL/EAGLE PORTFOLIOS JNL/PIMCO PORTFOLIOS 115 ___% Core Equity 078 ___% Real Return 116 ___% SmallCap Equity 127 ___% Total Return Bond JNL/FRANKLIN TEMPLETON PORTFOLIOS JNL/PPM AMERICA PORTFOLIOS 062 ___% Founding Strategy 105 ___% Core Equity 069 ___% Global Growth 136 ___% High Yield Bond 075 ___% Income 293 ___% Mid Cap Value 064 ___% Mutual Shares 294 ___% Small Cap Value 208 ___% Small Cap Value 106 ___% Value Equity JNL/GOLDMAN SACHS PORTFOLIOS JNL/SELECT PORTFOLIOS 110 ___% Core Plus Bond 104 ___% Balanced 207 ___% Mid Cap Value 107 ___% Money Market 076 ___% Short Duration Bond 179 ___% Value JNL/JPMORGAN PORTFOLIOS JNL/T. ROWE PRICE PORTFOLIOS 126 ___% International Value 111 ___% Established Growth 101 ___% MidCap Growth 112 ___% Mid-Cap Growth 109 ___% U.S. Government & Quality Bond 149 ___% Value JNL/LAZARD PORTFOLIOS JNL/S&P STRATEGIC PORTFOLIOS 077 ___% Emerging Markets 274 ___% Competitive Advantage 132 ___% Mid Cap Value 278 ___% Dividend Income & Growth 131 ___% Small Cap Value 279 ___% Intrinsic Value JNL/MELLON CAPITAL MANAGEMENT PORTFOLIOS 280 ___% Total Yield 242 ___% Index 5 292 ___% S&P 4 243 ___% 10 x 10 JNL/S&P MANAGED PORTFOLIOS 124 ___% S&P(R) 400 MidCap Index 227 ___% Conservative 123 ___% S&P 500(R) Index 226 ___% Moderate 133 ___% Bond Index 117 ___% Moderate Growth 129 ___% International Index 118 ___% Growth 128 ___% Small Cap Index 119 ___% Aggressive Growth 054 ___% Enhanced S&P 500 Stock Index JNL/S&P RETIREMENT PORTFOLIOS 224 ___% JNL 5 097 ___% Retirement Income 184 ___% 25 098 ___% Retirement 2015 186 ___% Select Small-Cap 099 ___% Retirement 2020 079 ___% JNL Optimized 5 100 ___% Retirement 2025 225 ___% VIP JNL/S&P DISCIPLINED PORTFOLIOS 096 ___% Dow Dividend 070 ___% Moderate 222 ___% Nasdaq(R) 25 071 ___% Moderate Growth 244 ___% NYSE(R) International 25 072 ___% Growth 074 ___% S&P 24 FIXED ACCOUNT OPTIONS 248 ___% S&P SMid 60 041 __% 1-year 043 __% 3-year 045 __% 5-year 047 __% 7-year TO SELECT CAPITAL PROTECTION PROGRAM OR AUTOMATIC REBALANCING, PLEASE SEE NEXT PAGE. ------------------------------------------------------------------------------------------------------------------------------------ Page 3 of 5 NVDA 220 04/08 NV4173 03/08 ------------------------------------------------------------------------------------------------------------------------------------ CAPITAL PROTECTION PROGRAM ------------------------------------------------------------------------------------------------------------------------------------ __ Yes - PLEASE COMPLETE SUPPLEMENTAL APPLICATION N3144. __ No - PLEASE COMPLETE THE PREMIUM ALLOCATION SECTION ON PAGE 3. ------------------------------------------------------------------------------------------------------------------------------------ SYSTEMATIC INVESTMENT ------------------------------------------------------------------------------------------------------------------------------------ __ CHECK HERE FOR AUTOMATIC REBALANCING. Only the Portfolios selected in the Premium Allocation Section and the 1-year Fixed Account (if selected) will participate in the program. The 3, 5 and 7 year Fixed Accounts are not available for Automatic Rebalancing. Frequency: __ Monthly __ Quarterly __Semi-Annual __ Annual Start Date:______________________ If no date is selected, the program will begin one month/quarter/half year/year (depending on the frequency you selected) from the date Jackson of NY(SM) applies the first premium payment. If no frequency is selected, the frequency will be annual. ------------------------------------------------------------------------------------------------------------------------------------ ELECTRONIC DELIVERY OF STATEMENTS/CORRESPONDENCE ------------------------------------------------------------------------------------------------------------------------------------ I (We) consent __ to electronic delivery of the following: __ quarterly statements __ prospectuses and prospectus supplements __ periodic and immediate confirmations __ proxy and other voting materials, related correspondence __ annual and semi-annual reports __ other documents from Jackson National Life Insurance Company of New York
This consent will continue unless and until revoked and will cover delivery to you in the form of a compact disc, by e-mail or by notice to you of a document's availability on a web-site. I (We) do not consent __ to electronic delivery for any of the documents listed above. The computer hardware and software requirements that are necessary to receive, process and retain electronic communications that are subject to this consent are as follows: To view and download material electronically, you must have a computer with Internet access, an active e-mail account, Adobe Acrobat Reader and/or a CD-ROM drive. If you don't already have Adobe Acrobat Reader, you can download it free from WWW.ADOBE.COM. I (We) do __ do not __ have ready access to computer hardware and software that meet the above requirements. My e-mail address is:__________________________. I (We) will notify the company of any new e-mail address. There is no charge for electronic delivery, although you may incur the costs of Internet access and of such computer and related hardware and software as may be necessary for you to receive, process and retain electronic documents and communications from Jackson of NY. Please make certain you have given Jackson of NY a current e-mail address. Also let Jackson of NY know if that e-mail address changes. We may need to notify you of a document's availability through e-mail. You may request paper copies, whether or not you consent or revoke your consent for electronic delivery, at any time and for no charge. Please contact the appropriate Jackson of NY Service Center or go to www.jnlny.com to update your e-mail address, revoke your consent to electronic delivery, or request paper copies. Even if you have given us consent, we are not required to make electronic delivery and we have the right to deliver any document or communication in paper form. This consent will need to be supplemented by specific electronic consent upon receipt of any of these means of electronic delivery or notice of availability. -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- MAILING ADDRESS AND CONTACT INFORMATION -------------------------------------------------------------------------------- IF PURCHASED THROUGH A NON-BANK BROKER/DEALER, SEND TO: REGULAR MAIL OVERNIGHT MAIL Jackson of NY(SM) Service Jackson of NY Service Center Center c/o Standard Federal Bank, P.O. Box 79001 Drawer 1633 Detroit, MI 38279-1633 12425 Merriman Rd. Livonia, MI 48150 OR REGULAR MAIL OVERNIGHT MAIL Jackson of NY Service Jackson of NY Service Center Center 7601 Technology Way P.O. Box 378004 Denver, CO 80237 Denver, CO 80237-8004 CUSTOMER CARE: 800/599-5651 (8:00 a.m. to 8:00 p.m. ET) FAX: 888/576-8383 E-MAIL: contactus@jnlny.com IF PURCHASED THROUGH A BANK OR FINANCIAL INSTITUTION, SEND TO: REGULAR MAIL OVERNIGHT MAIL Jackson of NY/IMG Service Jackson of NY/IMG Service Center Center P.O. Box 33178 c/o Standard Federal Bank Detroit, MI 48232-5178 Drawer 5178 12425 Merriman Rd. Livonia, MI 48150 CUSTOMER CARE: 800/777-7779 (8:00 a.m. to 8:00 p.m. ET) FAX: 517/706-5540 E-MAIL: contactus@jnlny.com -------------------------------------------------------------------------------- ----------------------------------------------------------------- Not FDIC/NCUA insured * Not Bank/CU guaranteed * May lose value * Not a deposit * Not insured by any federal agency ----------------------------------------------------------------- Page 4 of 5 NVDA 220 04/08 NV4173 03/08 -------------------------------------------------------------------------------- IMPORTANT - PLEASE READ CAREFULLY - SIGNATURE(S) REQUIRED BELOW - THIS ENTIRE SECTION MUST BE COMPLETED FOR "GOOD ORDER" -------------------------------------------------------------------------------- REPLACEMENT ARE YOU REPLACING AN EXISTING LIFE INSURANCE POLICY OR ANNUITY CONTRACT? ___ YES ___ NO IF "YES", PLEASE COMPLETE THIS SECTION. IF THE POLICY IS A REPLACEMENT PLEASE COMPLETE ALL NECESSARY FORMS AS REQUIRED BY NEW YORK REGULATION 60. -------------------------------------------------------------------------------- Company Name Contract No. Anticipated Transfer Amount $ -------------------------------------------------------------------------------- Company Name Contract No. Anticipated Transfer Amount $ -------------------------------------------------------------------------------- 1. I (We) hereby represent to the best of my (our) knowledge and belief that each of the statements and answers contained above are true, complete and correctly recorded. 2. I (We) certify that the Social Security or Taxpayer Identification number(s) shown above is (are) correct. 3. I (WE) UNDERSTAND THAT ANNUITY BENEFITS, DEATH BENEFIT VALUES AND WITHDRAWAL VALUES, IF ANY, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A PORTFOLIO IN THE SEPARATE ACCOUNT OF JACKSON OF NY ARE VARIABLE AND MAY BE INCREASED OR DECREASED, AND THE DOLLAR AMOUNTS ARE NOT GUARANTEED. 4. I (We) have been given a current prospectus for this variable annuity for each available Portfolio. 5. The contract I (we) have applied for is suitable for my (our) insurance objective, financial situation and needs. 6. I understand the restrictions imposed by 403(b)(11) of the Internal Revenue Code. I understand the investment alternatives available under my employer's 403(b) plan, to which I may elect to transfer my contract value. 7. I (WE) UNDERSTAND THAT ALLOCATIONS TO THE FIXED ACCOUNT OPTION(S) ARE SUBJECT TO AN ADJUSTMENT IF WITHDRAWN OR TRANSFERRED PRIOR TO THE END OF THE APPLICABLE PERIOD, WHICH MAY REDUCE AMOUNTS WITHDRAWN OR TRANSFERRED. 8. If I (we) have elected the Capital Protection Program, I (we) hereby acknowledge receipt of the "CAPITAL PROTECTION PROGRAM SUPPLEMENTAL APPLICATION." -------------------------------------------------------------------------------- SIGNATURES -------------------------------------------------------------------------------- Owner's Signature DATE SIGNED (MM/DD/YYYY) STATE WHERE SIGNED -------------------------------------------------------------------------------- Owner Title (if owned by an entity -------------------------------------------------------------------------------- Joint Owner's Signature Date Signed (mm/dd/yyyy) State where signed -------------------------------------------------------------------------------- Annuitant's Signature Date Signed (mm/dd/yyyy) State where signed (if other than Owner) -------------------------------------------------------------------------------- Joint Annuitant's Signature Date Signed (mm/dd/yyyy) State where signed (if other than Joint Owner) -------------------------------------------------------------------------------- PRODUCER/REPRESENTATIVE'S STATEMENT - SIGNATURE REQUIRED BELOW - THIS ENTIRE SECTION MUST BE COMPLETED FOR "GOOD ORDER" -------------------------------------------------------------------------------- I certify that: I am authorized and qualified to discuss the Contract herein applied for; I have fully explained the Contract to the client, including contract benefits, restrictions and charges; I believe this transaction is suitable given the client's financial situation and needs; I have complied with requirements for disclosures and/or replacements as necessary; and to the best of my knowledge and belief the applicant's statement as to whether or not an existing life insurance policy or annuity contract is being replaced is true and accurate. (If a replacement, please provide a replacement form or other special forms where required by state law.) --------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------- Producer/Representative's Full Name (First) (Middle) (Last) Phone No. (include area code) (please print) --------------------------------------------------------------------------------------------------------------- Producer/Representative's Signature Date Signed (mm/dd/yyyy) --------------------------------------------------------------------------------------------------------------- Address (number and street) City, State, ZIP (xxxxx-xxxx) --------------------------------------------------------------------------------------------------------------- E-Mail Address Contact your home office for program information. (If none indicated, designated default will be used.) __ Option A __ Option B __ Option C __ Option D __ Option E --------------------------------------------------------------------------------------------------------------- Broker/Dealer Name Broker/Dealer Representative No. Jackson of NY Producer/Representative No. ---------------------------------------------------------------------------------------------------------------
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