EX-99.5 4 a11-4934_1ex99d5.txt EX-99.5 APPLICATION FOR INDIVIDUALLY ALLOCATED [LOGO] GROUP ANNUITY CONTRACT ITT HARTFORD Hartford Life Insurance Company P.O. Box 2999 Hartford, CT 06104-2999 Application is hereby made for an Individually Allocated Group Annuity Contract: 1. Applicant-Contractholder: -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Street or P.O. Box -------------------------------------------------------------------------------- City State Zip Code 2. Nature of Applicant's Business: ---------------------------------- 3. Requested Effective Date of Contract: ------------------------------------ 4. Special Requests: ---------------------------------------------------- IT IS UNDERSTOOD THAT ALL PAYMENTS AND VALUES PROVIDED BY THE CONTRACT WHEN BASED ON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. Dated at: this day of , 19 --------------- ---- --------------- ---- For ----------------------------------- (Contractholder) ------------------------------------------- Registered Representative (Licensed Agent) By ------------------------------ ------------------------------ (Title)