EX-99 2 application_rl.txt APPLICATION EX-5.g RETIREMENT LATITUDES(SM) (04/09) JACKSON(SM) NATIONAL LIFE INSURANCE COMPANY FIXED AND VARIABLE ANNUITY APPLICATION (VA220) Home Office: Lansing, Michigan www.jackson.com -------------------------------------------------------------------------------- CUSTOMER CARE: 800/873-5654 BANK OR FINANCIAL INSTITUTION CUSTOMER CARE: 800/777-7779 HOURS: 8:00 a.m. to 8:00 p.m. ET FAX: 800/943-6761 E-MAIL: contactus@jackson.com FIRST CLASS MAIL: P.O. Box 30314 Lansing, MI 48909-7814 OVERNIGHT MAIL: 1 Corporate Way Lansing, MI 48951 -------------------------------------------------------------------------------- Broker/Dealer/External Account No. (if applicable) Trade No. (if applicable) --------------------------------------------------------------------------------
-------------------------------------------------------------------------------- USE DARK INK ONLY - ALL PAGES MUST BE COMPLETED FOR "GOOD ORDER" ------------------------------------------------------------------------------------------------------------------------------------ REGISTRATION INFORMATION - PLEASE PRINT ------------------------------------------------------------------------------------------------------------------------------------ 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) ------------------------------------------------------------------------------------------------------------------------------------ Physical Address (Required) CITY STATE ZIP ------------------------------------------------------------------------------------------------------------------------------------ Mailing Address (if different from Physical Address) CITY STATE ZIP ------------------------------------------------------------------------------------------------------------------------------------ Sex U.S. Citizen Phone No. (include area code) E-Mail Address __ 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) ------------------------------------------------------------------------------------------------------------------------------------ Physical Address (Required) CITY STATE ZIP Relationship to Owner (Check One) ___ Spouse ___ Other _________________ ------------------------------------------------------------------------------------------------------------------------------------ Date of Birth (mm/dd/yyyy) 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) ------------------------------------------------------------------------------------------------------------------------------------ Physical Address (number and street) CITY STATE ZIP Relationship to Owner (Check One) ___ Spouse ___ Other _________________ ------------------------------------------------------------------------------------------------------------------------------------ Date of Birth (mm/dd/yyyy) 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) ------------------------------------------------------------------------------------------------------------------------------------ Physical Address (number and street) CITY STATE ZIP Relationship to Owner (Check One) ___ Spouse ___ Other _________________ ------------------------------------------------------------------------------------------------------------------------------------ Date of Birth (mm/dd/yyyy) Sex U.S. Citizen Phone No. (include area code) __ M __ F __ Yes __ No ------------------------------------------------------------------------------------------------------------------------------------
ARIZONA RESIDENTS, PLEASE NOTE: RIGHT TO EXAMINE. On written request, the Company will provide to the contract Owner, within a reasonable time, reasonable factual information regarding the benefits and provisions of this Contract. If, for any reason, the contract Owner is not satisfied, the Contract may be returned to the Company or agent within 10 days (30 days if YOU WERE AGE 65 OR OLDER ON THE DATE THE APPLICATION WAS SIGNED or it was purchased as a replacement contract) after delivery and the Contract Value, without deductions for any sales charges for the business day on which the Contract is received at its Service Center, will be returned. VDA 310 04/09 V5673 04/09
------------------------------------------------------------------------------------------------------------------------------------ BENEFICIARY DESIGNATION - PLEASE PRINT ------------------------------------------------------------------------------------------------------------------------------------ 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 _________________ ------------------------------------------------------------------------------------------------------------------------------------ __ Primary Name ___ SSN ___ TIN (include dashes) Percentage (%) __ Contingent --------------------------------------------------------------------------------------------------------------------- Relationship to Owner Address (number and street) City, State, ZIP ------------------------------------------------------------------------------------------------------------------------------------ __ Primary Name ___ SSN ___ TIN (include dashes) Percentage (%) __ Contingent --------------------------------------------------------------------------------------------------------------------- Relationship to Owner Address (number and street) City, State, ZIP ------------------------------------------------------------------------------------------------------------------------------------ __ Primary Name ___ SSN ___ TIN (include dashes) Percentage (%) __ Contingent --------------------------------------------------------------------------------------------------------------------- Relationship to Owner Address (number and street) City, State, ZIP ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ANNUITY TYPE ------------------------------------------------------------------------------------------------------------------------------------ __ IRA-Traditional* __ IRA - SEP __ Non-Tax Qualified __ IRA - Roth* __ IRA - Stretch __ 401(k) Qualified Savings Plan *Tax Contribution Years and Amounts: __ Corporate Pension Plan __ HR-10 (Keogh) Plan Year:______ $______ __ 403(b) TSA (Direct Transfer Only) Year:______ $______ __ Other -________ ------------------------------------------------------------------------------------------------------------------------------------ TRANSFER INFORMATION ------------------------------------------------------------------------------------------------------------------------------------ Transfer request submitted directly to another institution? __ Yes __ No Non-Qualified Plans Only If yes, complete the following: __ IRC 1035 Exchange Anticipated Amount: $________________ __ Non-1035 Exchange Anticipated Date of Receipt (mm/dd/yyyy): ________________ Qualified Plans Only Institution releasing funds: _____________________________________ __ Direct Transfer Account Number: __________________________________________________ __ Direct Rollover FOR APPLICANT INITIATED TRANSFERS, JACKSON(SM) WILL NOT TAKE ANY ACTION TO INITIATE THIS TRANSFER __ Non-Direct Rollover UNLESS WE ARE INSTRUCTED OTHERWISE. ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ INITIAL PREMIUM ANNUITIZATION INCOME DATE ------------------------------------------------------------------------------------------------------------------------------------ Amount of premium with application: $__________________ PLEASE SPECIFY DATE (mm/dd/yyyy):__________________ __ Check or __ Wire (check one) If an Income Date is not specified, the Company will MAKE ALL CHECKS PAYABLE TO JACKSON NATIONAL LIFE INSURANCE COMPANY(R) default to the Latest Income Date as shown in the contract. ------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------- STATEMENT REGARDING EXISTING POLICIES OR ANNUITY CONTRACTS - MUST COMPLETE FOR "GOOD ORDER" ----------------------------------------------------------------------------------------------------------------------------- I (We) certify that: (check one) __ I (We) do not have any existing life insurance policies or annuity contracts. __ I (We) do have existing life insurance policies or annuity contracts. PRODUCER: IF THE APPLICANT DOES HAVE EXISTING LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS YOU MUST PRESENT AND READ TO THE APPLICANT THE NOTICE REGARDING REPLACEMENT (X0512 - STATE VARIATIONS MAY APPLY) AND RETURN THE NOTICE SIGNED BY BOTH THE PRODUCER AND THE APPLICANT, WITH THE APPLICATION COMPLETE X0512 WHERE REQUIRED ------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------- REPLACEMENT ----------------------------------------------------------------------------------------------------------------------------- Are you replacing an existing life insurance policy or annuity contract? (check one) __ No __ Yes If "Yes", complete the following replaced company information. ----------------------------------------------------------------------------------------------------------------------------- Company Name Contract No. Anticipated Transfer Amount $ ----------------------------------------------------------------------------------------------------------------------------- Company Name Contract No. Anticipated Transfer Amount $ ------------------------------------------------------------------------------------------------------------------------------------ VDA 310 04/09 Page 2 of 6 V5673 04/09 ------------------------------------------------------------------------------------------------------------------------------------ OPTIONAL DEATH BENEFITS ALL OPTIONAL DEATH BENEFITS MAY NOT BE AVAILABLE IN ALL STATES AND ONCE SELECTED CANNOT BE CHANGED. ------------------------------------------------------------------------------------------------------------------------------------ If no Optional Death Benefit is selected your beneficiary(ies) will receive the standard death benefit. Please see the prospectus for details. May select only one Optional Death Benefit: (Owner Ages 0-79) 1. ___ 5% Roll-Up Death Benefit (4% if the Owner is age 70 or older on the date of issue) 2. ___ 6% Roll-Up Death Benefit (5% if the Owner is age 70 or older on the date of issue) 3. ___ Highest Anniversary Value Death Benefit. 4. ___ Combination of Options 1 and 3 above. 5. ___ Combination of Options 2 and 3 above. ADDITIONAL CHARGES WILL APPLY. PLEASE SEE THE PROSPECTUS FOR DETAILS. ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ OTHER OPTIONAL BENEFITS ALL OPTIONAL BENEFITS MAY NOT BE AVAILABLE IN ALL STATES AND ONCE SELECTED CANNOT BE CHANGED. Age limitations apply based on the age of the Annuitant(s), Owner(s) or Covered Lives. Please see the prospectus for details. ------------------------------------------------------------------------------------------------------------------------------------ A. EARNINGS PROTECTION BENEFIT D. GUARANTEED LIVING BENEFIT OPTIONS (continued) __ EarningsMax(R)(Ages 0-75) Guaranteed Minimum Withdrawal Benefits (GMWB) B. WITHDRAWAL OPTIONS (MAY SELECT ONLY ONE) __ SAFEGUARD MAX(SM)(Ages 0-85) __ 20% Free Withdrawal Benefit (1)(2) (GMWB with 5-Year Step-Up) __ 4-Year Withdrawal Charge Schedule (2) __ AUTOGUARD 5(SM)(Ages 0-80) (5% GMWB with Annual Step-Up) C. CONTRACT ENHANCEMENT OPTIONS (Ages 0-87) __ LIFEGUARD FREEDOM(SM) (Ages 45-80) (MAY SELECT ONLY ONE) (For Life GMWB with Bonus, GWB Adjustment, & Annual Step-Up) __ 4% of first-year premium __ LIFEGUARD FREEDOM DB(SM)(3) (Ages 45-75) __ 5% of first-year premium (2) (For Life GMWB with Bonus, GWB Adjustment, Annual Step-Up, & Death Benefit) D. GUARANTEED LIVING BENEFIT OPTIONS __ LIFEGUARD FREEDOM WITH JOINT OPTION(4)(5) (Ages 45-80) (MAY SELECT ONLY ONE GMIB OR GMWB) (Joint For Life GMWB with Bonus, GWB Adjustment, & Annual Step-Up) Guaranteed Minimum Income Benefit (GMIB) __ FUTUREGUARD 6(SM)(Ages 0-75) ADDITIONAL CHARGES WILL APPLY. PLEASE SEE THE PROSPECTUS FOR DETAILS. (1) May not be selected in combination with either the 4% or 5% Contract Enhancements. (2) If selected, premium payments will not be accepted after the first Contract Year. (3) May not be selected in combination with an Optional Death Benefit. (4) For Non-Qualified plans, spousal joint ownership required unless non-natural owner, then spousal joint annuitants required. Please ensure the Joint Owner section on Page 1 (including the "Relationship to Owner" box) is properly completed. (5) For Qualified plans, 100% spousal primary beneficiary designation required. Please ensure the Primary Beneficiary section on Page 2 (including the "Relationship to Owner" box) is properly completed. Not available on Custodial Accounts. ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ SYSTEMATIC INVESTMENT ------------------------------------------------------------------------------------------------------------------------------------ ___ CHECK HERE FOR AUTOMATIC REBALANCING. Only the DCA+ ($15,000 CONTRACT MINIMUM) Investment Division(s) selected in the Premium Allocation 030 ____% 6-month Section and the 1-year Fixed Account (if selected) will 032 ____% 12-month participate in the program. The 3-, 5- and 7-year Fixed Accounts are not available for Automatic Rebalancing. IF DCA+ IS SELECTED, YOU MUST ATTACH THE SYSTEMATIC INVESTMENT FORM (V2375). Frequency: ___ Monthly ___ Quarterly ___ Semi-Annual ___ Annual DCA+ provides an automatic monthly transfer to the selected Investment Division(s) so the entire amount invested in this Start Date: ___________________________________________ program, plus earnings, will be transferred by the end of the DCA+ term selected. If selected, the total number of elections If no date is selected, the program will begin one in the Premium Allocation section may not exceed 17. month/quarter/half year/year (depending on the frequency you selected) from the date Jackson applies the first premium payment. If no frequency is selected, the frequency will be annual. No transfers made on days 29, 30, or 31, unless set up on an annual frequency. ------------------------------------------------------------------------------------------------------------------------------------ Page 3 of 6 VDA 310 04/09 V5673 04/09 ------------------------------------------------------------------------------------------------------------------------------------ PLEASE SELECT FROM THE FOLLOWING INVESTMENT DIVISIONS AND FIXED ACCOUNT OPTIONS PREMIUM ALLOCATION TOTAL NUMBER OF ELECTIONS BELOW MAY NOT EXCEED 18 * TOTAL ALLOCATION MUST EQUAL 100% ------------------------------------------------------------------------------------------------------------------------------------ Investment Divisions NUMBER JNL(R)/AIM NUMBER JNL/MELLON (CONTINUED) 113 ___% International Growth 074 ___% S&P 24 196 ___% Large Cap Growth 223 ___% Value Line(R) 30 206 ___% Global Real Estate 123 ___% S&P 500(R) Index 195 ___% Small Cap Growth 124 ___% S&P(R) 400 MidCap Index JNL/CAPITAL GUARDIAN 128 ___% Small Cap Index 150 ___% Global Balanced 129 ___% International Index 103 ___% Global Diversified Research 133 ___% Bond Index 250 ___% International Small Cap 187 ___% Technology Sector 102 ___% U.S. Growth Equity 054 ___% Enhanced S&P 500 Stock Index JNL/CREDIT SUISSE JNL/OPPENHEIMER 066 ___% Global Natural Resources 173 ___% Global Growth 068 ___% Long/Short JNL/PAM JNL/EAGLE 272 ___% Asia ex-Japan 115 ___% Core Equity 273 ___% China-India 116 ___% SmallCap Equity JNL/PIMCO JNL/FRANKLIN TEMPLETON 078 ___% Real Return 062 ___% Founding Strategy 127 ___% Total Return Bond 069 ___% Global Growth JNL/PPM AMERICA 075 ___% Income 105 ___% Core Equity 064 ___% Mutual Shares 136 ___% High Yield Bond 208 ___% Small Cap Value 293 ___% Mid Cap Value JNL/GOLDMAN SACHS 294 ___% Small Cap Value 110 ___% Core Plus Bond 106 ___% Value Equity 059 ___% Emerging Markets Debt JNL/RED ROCKS 207 ___% Mid Cap Value 300 ___% Listed Private Equity 076 ___% Short Duration Bond JNL/SELECT JNL/JPMORGAN 104 ___% Balanced 126 ___% International Value 107 ___% Money Market 101 ___% MidCap Growth 179 ___% Value 109 ___% U.S. Government & Quality Bond JNL/T. ROWE PRICE JNL/LAZARD 111 ___% Established Growth 077 ___% Emerging Markets 112 ___% Mid-Cap Growth 132 ___% Mid Cap Equity 149 ___% Value JNL/M&G JNL/S&P STRATEGIC 060 ___% Global Basics 292 ___% S&P 4 061 ___% Global Leaders JNL/S&P MANAGED JNL/MELLON CAPITAL MANAGEMENT 227 ___% Conservative 224 ___% JNL 5 226 ___% Moderate 145 ___% Dow (SM) 10 117 ___% Moderate Growth 193 ___% S&P 10 118 ___% Growth 183 ___% Global 15 119 ___% Aggressive Growth 184 ___% 25 JNL/S&P DISCIPLINED 186 ___% Select Small-Cap 070 ___% Moderate 079 ___% JNL Optimized 5 071 ___% Moderate Growth 225 ___% VIP 072 ___% Growth 096 ___% Dow Dividend FIXED ACCOUNT OPTIONS 299 ___% European 30 041 ___% 1-Year 222 ___% Nasdaq(R) 25 043 ___% 3-Year 298 ___% Pacific Rim 30 045 ___% 5-Year 047 ___% 7-Year TO SELECT CAPITAL PROTECTION PROGRAM, PLEASE SEE NEXT PAGE. ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ALL INVESTMENT DIVISIONS AND FIXED ACCOUNT OPTIONS MAY NOT BE AVAILABLE IN ALL STATES. RESTRICTIONS MAY APPLY AT JACKSON'S DISCRETION ON A NON-DISCRIMINATORY BASIS. ----------------------------------------------------------------------------------------------------------------------------------- Page 4 of 6 VDA 310 04/09 V5673 04/09 ----------------------------------------------------------------------------------------------------------------------------- CAPITAL PROTECTION PROGRAM ----------------------------------------------------------------------------------------------------------------------------- __ Yes __ No (If no selection is made, Jackson(SM) will default to "No.") If you marked "Yes", which Fixed Account Option do you wish to select for the Capital Protection Program? Select only one. __ 1-Year __ 3-Year __ 5-Year __ 7-Year Having selected the Capital Protection Program, the balance of your initial premium will be allocated as indicated in the Premium Allocation Section on page 4. ------------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------- TELEPHONE/ELECTRONIC TRANSFERS AUTHORIZATION -------------------------------------------------------------------------------- DO YOU WISH TO AUTHORIZE THESE TYPES OF TRANSFERS? ___ Yes ____ No By checking "Yes", I (We) authorize Jackson National Life Insurance Company (Jackson) to accept fund transfers/allocation changes via telephone, Internet, or other electronic medium from me (us) and my (our) Representative subject to Jackson's administrative procedures. Jackson has administrative procedures that are designed to provide reasonable assurances that telephone/electronic authorizations are genuine. If Jackson fails to employ such procedures, it may be held liable for losses resulting from a failure to use such procedures. I (We) agree that Jackson, its affiliates, and subsidiaries shall not be liable for losses incurred in connection with telephone/electronic instructions received, and acted on in good faith, notwithstanding subsequent allegations of error or mistake in connection with any such transaction instruction. IF NO ELECTION IS MADE, JACKSON WILL DEFAULT TO "NO" FOR RESIDENTS OF NORTH DAKOTA, NEBRASKA AND NEW HAMPSHIRE AND TO "YES" FOR RESIDENTS OF ALL OTHER STATES. -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- ELECTRONIC DELIVERY OF STATEMENTS/CORRESPONDENCE -------------------------------------------------------------------------------- I (We) consent __ to electronic delivery of the following: __ quarterly statements __ prospectuses and prospectus supplements __ periodic and immediate __ proxy and other voting materials, related confirmations correspondence __ annual and semi-annual __ other documents from Jackson National Life reports Insurance Company. 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. Please make certain you have given Jackson a current e-mail address. Also let Jackson 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 Service Center or go to www.jackson.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. -------------------------------------------------------------------------------- NOTICE TO APPLICANT: ARKANSAS, COLORADO, KENTUCKY, LOUISIANA, MAINE, NEW MEXICO, OHIO, OKLAHOMA, PENNSYLVANIA, TENNESSEE, AND WEST VIRGINIA RESIDENTS, PLEASE NOTE: 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 such person to criminal and civil penalties. In COLORADO, any insurance company, or agent of an insurance company, who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding, or attempting to defraud, the policyholder or claimant with regard to a settlement or award payable from insurance proceeds, shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. DISTRICT OF COLUMBIA RESIDENTS PLEASE NOTE: It is a crime to knowingly provide FALSE, incomplete or MISLEADING information to an insurance company for the purpose of defrauding the company or any other person. Penalties may include imprisonment, fines and/or a denial of insurance benefits. MARYLAND RESIDENTS, PLEASE NOTE: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. -------------------------------------------------------------------------------- Page 5 of 6 VDA 310 04/09 V5673 04/09 -------------------------------------------------------------------------------- IMPORTANT - PLEASE READ CAREFULLY - SIGNATURE(S) REQUIRED BELOW - -------------------------------------------------------------------------------- 1. I (We) hereby represent to the best of my (our) knowledge and belief that each of the statements and answers contained in this application 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 AN INVESTMENT DIVISION IN THE SEPARATE ACCOUNT OF JACKSON 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 and for each available Investment Division 5. The contract I (We) have applied for is suitable for my (our) insurance and investment objectives, 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 OPTIONS ARE SUBJECT TO AN ADJUSTMENT IF WITHDRAWN OR TRANSFERRED PRIOR TO THE END OF THE APPLICABLE PERIOD, WHICH MAY REDUCE AMOUNTS WITHDRAWN OR TRANSFERRED. *. I (We) certify that the age of the Owner and any Joint Owner, primary spousal Beneficiary, Annuitant or Joint Annuitant, if applicable, stated in this application are true and correctly recorded for purposes of electing an Optional Death Benefit or Other Optional Benefits. -------------------------------------------------------------------------------- OWNER'S NAME (Please print) OWNER TITLE (IF OWNED BY AN ENTITY) -------------------------------------------------------------------------------- OWNER'S SIGNATURE DATE SIGNED (MM/DD/YYYY) STATE WHERE SIGNED -------------------------------------------------------------------------------- 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 INFORMATION - PLEASE PRINT ---------------------------------------------------------------------------------------------------------------- Producer/Representative's Full Name (First) (Middle) (Last) Phone No. (include area code) (please print) ---------------------------------------------------------------------------------------------------------------- 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 ---------------------------------------------------------------------------------------------------------------- Broker/Dealer Name Broker/Dealer Representative No. Jackson Producer/Representative No. ----------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------- PRODUCER/REPRESENTATIVE'S STATEMENT - SIGNATURE(S) REQUIRED BELOW - THIS ENTIRE SECTION MUST BE COMPLETED FOR "GOOD ORDER" -------------------------------------------------------------------------------- PRODUCER/REPRESENTATIVE'S CERTIFICATION REGARDING SALES MATERIAL Important Note: Complete this certification section only if the applicant answered affirmatively to the Statement Regarding Existing Policies or Annuity Contracts AND answered "Yes" to EITHER question 1 or 2 on the Notice Regarding Replacement (Form X0512 - state variations may apply). I certify that:(check one) __ I did not use sales material(s) during the presentation of this Jackson product to the applicant. __ I used only Jackson-approved sales material(s) during the presentation of this Jackson product to the applicant. In addition, copies of all approved sales material(s) used during the presentation were left with the applicant. I have read Jackson's Position With Respect to the Acceptability of Replacements (XADV5790 - state variations may apply) and ensure that this replacement (if applicable) is consistent with that position. By signing this form, I certify that the statement regarding any applicable life insurance policies or annuity contracts and the statement regarding sales material have been answered correctly to the best of my knowledge. 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 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. -------------------------------------------------------------------------------- Producer/Representative's Signature Date Signed (mm/dd/yyyy) -------------------------------------------------------------------------------- ------------------------------------------------------------------------- Not FDIC/NCUA insured * Not Bank/CU guaranteed * May lose value Not a deposit * Not insured by any federal agency ------------------------------------------------------------------------- Page 6 of 6 VDA 310 04/09 V5673 04/09