v630.htm

EX-5j

RETIREMENT LATITUDES
(10/10) VARIABLE AND FIXED

ANNUITY APPLICATION (VA630)

Home Office: Lansing, Michigan

www.jackson.com

First Class Mail: P.O. Box 30314

Customer Care: 800-873-5654

Lansing, MI 48909-7814

Bank or Financial Institution Customer Care: 800-777-7779

Fax: 800-943-6761

Overnight Mail:

1 Corporate Way

Hours: 8:00 a.m. to 8:00 p.m. ET

Lansing, MI 48951

Email: contactus@jackson.com

Broker/Dealer or External Account No. (if applicable)

PLEASE PRINT

Primary Owner

If Owner

Type of Ownership:

Individual/Joint

Trust

Custodian

Corporation/Pension Plan

(and/or Joint

Owner) is not a

Social Security Number

Tax I.D. Number

U.S. Citizen

Sex

Male

Female

and/or a U.S.

U.S. Citizen

Yes

Resident, Form
W-9 or Form

First Name

Middle Name

Last Name

W-8BEN (as
applicable) is
required with
application.

Non-Natural Owner/Entity Name (if applicable)

If Owner is a

Trust, Trustee
Certification

Date of Birth

(mm/dd/yyyy)

Telephone Number(including area code)

Email Address

form X5335 or

trust

(

)

documents are

required with

Physical Address Line 1 (No P.O. Boxes)

Line 2

application.

It is required
for Good

City

State

ZIP Code

Order that you
provide a
physical

address.

Mailing Address Line 1

Line 2

Only include
mailing

address if

City

State

ZIP Code

different from
physical

address.

Joint Owner

First Name

Middle Name

Last Name

Proceeds will
be distributed
in accordance

Social Security Number

Date of Birth (mm/dd/yyyy)

Sex

U.S. Citizen

with the

Male Female

Yes

Contract on

the first death
of either

Email Address

Relationship to Owner

Telephone Number (including area code)

Owner.

Spouse

(

)

Other__________________

Physical Address Line 1 (No P.O. Boxes)

Line 2

City

State

ZIP Code

VDA 630 10/10

Page 1 of 9

V630 10/10

LONG-TERM SMART

Primary Annuitant

Same as Owner

Sex Male

Female

U.S. Citizen Yes

Complete this

First Name

Middle Name

Last Name

section if

different from

Owner.

Social Security Number

Date of Birth (mm/dd/yyyy)

Telephone No. (including area code)

Relationship to Owner

Spouse

(

)

Other__________________

Physical Address Line 1 (No P.O. Boxes)

Line 2

City

State

ZIP Code

Joint/Contingent Annuitant

Joint Annuitant OR

Contingent Annuitant

Sex Male

Female

U.S. Citizen Yes

Same as Joint Owner

Complete this

section if

First Name

Middle Name

Last Name

different from

Joint Owner.

Contingent

Social Security Number

Date of Birth (mm/dd/yyyy)

Telephone No. (including area code)

Relationship to Owner

Annuitant

Spouse

must be

(

)

Other__________________

Annuitant's

Physical Address Line 1 (No P.O. Boxes)

Line 2

spouse.

Available only
on a Qualified

plan custodial

City

State

ZIP Code

account when
electing a Joint
GMWB.

Beneficiary(ies)

It is required for

Primary

Percentage of Death Benefit

Good Order

that the Death

Individual Name (First, Middle, Last) or Non-Natural Entity Name

Benefit

Percentage be

whole numbers

and must total

Social Security/Tax I.D. Number Date of Birth

(mm/dd/yyyy)

Relationship to Owner

100% for each

Spouse

beneficiary

Other__________________

type.

Primary

Contingent

Percentage of Death Benefit

For additional

Individual Name (First, Middle, Last) or Non-Natural Entity Name

beneficiaries,

please attach a
separate sheet,

signed and

Social Security/Tax I.D. Number Date of Birth

(mm/dd/yyyy)

Relationship to Owner

dated by the

Owner, which
includes names,
percentages,

Primary

Contingent

Percentage of Death Benefit

and other
required

Individual Name (First, Middle, Last) or Non-Natural Entity Name

information.

Social Security/Tax I.D. Number Date of Birth

(mm/dd/yyyy)

Relationship to Owner

VDA 630 10/10

Page 2 of 9

V630 10/10

LONG-TERM SMART

Make all

Premium Payment

checks

payable to

Select method of payment

Jackson

Check

$___________________________

Wire

$___________________________

National Life

Insurance

External Transfer

$___________________

Internal Transfer

$___________________

Company .

Annuity Type

Jackson will

IRA:

Qualified Plan:

SEP/IRA

(408(k)):

issue Annuity

IRA - Traditional*

401(k) Qualified Savings Plan

SARSEP

Type per the

Stretch IRA

Cash Balance-Defined Benefit

SEP

bold

Roth IRA:

Cash Balance-Defined Contribution

ORP:

headings.

Roth Conversion

HR-10 (Keogh) Plan

ORP

Roth IRA*

Money Purchase

Texas ORP

*Tax Contribution Years and Amounts:

Profit Sharing Plan

Charitable Remainder Trust:

Year:________ $___________

Roth 401(k)

Charitable Remainder

Year:________ $___________

Target Benefit Plan

Annuity Trust

Charitable Remainder

Non-Qualified Plan:

TSA Plan:

Unitrust

Deferred Compensation

403(b) TSA

Non-Tax Qualified

It is required for

Statement Regarding Existing Policies or Annuity Contracts

Good Order

I (We) certify that:

(please select one)

that this entire

section be

I (We) do not have any existing life insurance policies or annuity contracts.

completed.

COMPLETE

I (We) do have existing life insurance policies or annuity contracts.

X0512

Notice to Producer/Representative: If the Applicant does have existing life insurance policies or annuity contracts you

" REPLACEMENT

must present and read to the Applicant the Replacement of Life Insurance or Annuities form (X0512 - state variations

OF LIFE

may apply) and return the notice, signed by both the Producer/Representative and Applicant, with the Application.

INSURANCE OR

If yes, complete the

Yes

ANNUITIES"

following Company

Are you replacing an existing life insurance policy or annuity contract?

WHERE

information.

REQUIRED

Company name

Contract number

Anticipated amount

(must be dated

on or before the

Application Sign
Date to be in

Good Order).

Transfer Information

For transfers,

Non-Qualified Plan Types:

IRC 1035 Exchange

Non-1035 Exchange

it is required

All Other Plan Types:

Direct Transfer

Direct Rollover

Non-Direct Rollover

for Good

Order that this

Please check the appropriate box(es) under the " Transfer Type" and " Client Initiated" headings. If you have

entire section

already, or plan to submit a transfer request to the surrendering institution, please select " Yes" under " Client

be completed.

Initiated." Jackson will only request the funds if this section is left blank or checked " No."

Transfer

Client

Anticipated date

Anticipated

Type

Initiated

Company releasing funds

Account number

of receipt

transfer amount

Full

Yes

Partial

Full

Yes

Partial

Full

Yes

Partial

Annuitization/Income Date

Specify Income Date (mm/dd/yyyy)

If an Income Date is not specified, the Company will default

to the Latest Income Date as shown in the Contract.

VDA 630 10/10

Page 3 of 9

V630 10/10

LONG-TERM SMART

Optional Death Benefits All optional death benefits may not be available in all states and once selected cannot be changed.

If no Optional

Select only one of the following. May not be selected in combination with LifeGuard Freedom Flex DB.

Death Benefit

5% Roll-Up Death Benefit

(4% if the owner is age 70 or older on the date of issue)

(Ages 0-79)

is selected

your

With Highest Quarterly Anniversary Value Death Benefit

beneficiary(ies)

will receive the

Without Highest Quarterly Anniversary Value Death Benefit

standard

death benefit.

6% Roll-Up Death Benefit

(5% if the Owner is age 70 or older on the date of issue)

(Ages 0-79)

Please see the

With Highest Quarterly Anniversary Value Death Benefit

prospectus for

details.

Without Highest Quarterly Anniversary Value Death Benefit

Optional

Highest Quarterly Anniversary Value Death Benefit

(Ages 0-79)

Death

Benefits and

Other Optional Benefits All optional benefits may not be available in all states and once selected cannot be changed.

Other

Guaranteed Living Benefit Options

(May select only one GMWB)

Optional

Benefits:

GMWB For Life

Additional

charges will

(For Life Guaranteed Minimum Withdrawal Benefits)

apply. Please

LifeGuard Freedom Flex

see the

LifeGuard Freedom 6 Net

For Life GMWB with Owner's choice of

prospectus

For Life GMWB with Bonus, Annual Step-Up,

for details.

Bonus and Step-Up

(Ages 35-80)

& Earnings-Sensitive Withdrawal Amount

(Ages 45-80)

Bonus

Step-Up

1,2,3

LifeGuard Freedom 6 Net w/ Joint Option

(Must select one)

Election Age

Joint For Life GMWB with Bonus, Annual Step-Up,

Annual

limitations

& Earnings-Sensitive Withdrawal Amount

(Ages 45-80)

apply based

Annual to Highest

Jackson Select

on the age of

Quarterly Contract Value*

For Life GMWB with Bonus, GWB Adjustment,

the Owner(s)

* Not available with 8% bonus

Annual Step-Up, & Transfer of Assets

(Ages 55-80)

or Covered

Lives.

1,2,3

1,2,3,5

LifeGuard Freedom Flex w/ Joint Option

Jackson Select w/ Joint Option

Joint For Life GMWB with Bonus, GWB Adjustment,

For Life GMWB with Owner's choice of

Annual Step-Up, & Transfer of Assets

(Ages 55-80)

Bonus and Step-Up

(Ages 35-80)

Bonus

Step-Up

(Must select one)

GMWB

(Guaranteed Minimum Withdrawal Benefits)

Annual

Annual to Highest

SafeGuard Max

Quarterly Contract Value*

GMWB with 5-Year Step-Up

(Ages 0-85)

*Not available with 7% bonus

AutoGuard

5% GMWB with Annual Step-Up

(Ages 0-80)

LifeGuard Freedom Flex DB

For Life GMWB with 6% Bonus, Annual Step-Up,

and Death Benefit

(Ages 35-70)

Contract Enhancement Options

Withdrawal Options

(May select only one)

(Ages 0-87)

(May select only one)

6,7

5% of first year premium

20% Free Withdrawal Benefit

(Ages 0-90)

4% of first year premium

4-Year Withdrawal Charge Schedule

(Ages 0-85)

Earnings Protection Benefit

EarningsMax

(Ages 0-75)

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. For
Qualified plans, excluding custodial accounts, 100% spousal primary beneficiary designation is required. Please ensure the
Primary Beneficiary section on Page 2 (including the "Relationship to Owner" box) is properly completed. For Qualified plan
custodial accounts, Annuitant's spouse must be designated as Contingent Annuitant. May not be selected in combination with
an Optional Death Benefit.

If selected, the 3, 5, and 7-Year Fixed Account Options and the Capital Protection Program are not available. The total number
of allocations in the Premium Allocation section may not exceed 17.

May not be selected in combination with either the 4% or 5% Contract
Enhancements. If selected, premium payments will not be accepted after the first
Contract Year.

VDA 630 10/10

Page 4 of 9

V630 10/10

LONG-TERM SMART

Premium Allocation

JNL®

JNL/Ivy

JNL/PPM America

Tell us how you

want your

% Institutional Alt 20

% Asset Strategy

% High Yield Bond

annuity

% Institutional Alt 35

% Mid Cap Value

premiums

invested.

% Institutional Alt 50

% Small Cap Value

TOTAL

% Institutional Alt 65

JNL/JPMorgan

% Value Equity

ALLOCATION

% International Value

MUST EQUAL

% U.S. Government &

100%.

JNL/American Funds®

Quality Bond

Blue Chip Income

Total number

and Growth

JNL/Red Rocks

of allocation

% Global Bond

% Listed Private Equity

JNL/Lazard

selections may

not exceed 18.

Global Small

% Emerging Markets

Capitalization

% Growth-Income

% International

JNL/Select

JNL/M&G

% New World

% Balanced

All premium

% Global Basics

allocation

% Money Market

% Global Leaders

options may

% Value

not be

JNL/BlackRock

available in all

% Commodity Securities

states.

Restrictions

% Global Allocation

JNL/Mellon Capital Management

may apply at

Jackson's

% JNL 5

JNL/T. Rowe Price

discretion on a

% Global 15

non-

JNL/Capital Guardian

% Established Growth

% Select Small-Cap

discriminatory

% Global Balanced

% Mid-Cap Growth

basis.

% JNL Optimized 5

Global Diversified

% Short-Term Bond

Research

% VIP

% U.S. Growth Equity

% Value

% Dow Dividend

% Nasdaq

% S&P

JNL/Eagle

% Value Line

% Core Equity

JNL/S&P

% SmallCap Equity

% S&P 500 Index

% 4

% S&P 400 MidCap
Index % Small Cap Index

JNL/Franklin Templeton

% International Index

% Founding Strategy

JNL/S&P Managed

% Bond Index

% Income

% Conservative

% Global Alpha

% International Small

% Moderate

Cap Growth

% Moderate Growth

% Growth

JNL/PAM

JNL/Goldman Sachs

% Aggressive Growth

% Asia ex-Japan

% Core Plus Bond

% China-India

% Emerging Markets Debt

JNL/S&P Disciplined

JNL/Invesco

% Global Real Estate

JNL/PIMCO

% Moderate

% International Growth

% Real Return

% Moderate Growth

% Large Cap Growth

% Total Return Bond

% Growth

PREMIUM ALLOCATIONS CONTINUED ON PAGE 6.

VDA 630 10/10

Page 5 of 9

V630 10/10

LONG-TERM SMART

Premium Allocation(Cont. from page 5)

See the NOTE

Fixed Account Options

for some

% 1-Year

important

terms

% 3-Year

regarding the

% 5-Year

Fixed Account

Options.

% 7-Year

NOTE: The Contract permits Jackson without advance notice to restrict the amount of Premium payments into, and the amount
and frequency of transfers between, into and from, any Fixed Account Option; to close any Fixed Account Option; and to require
transfers from a Fixed Account Option. Accordingly, you should consider whether investment in a Fixed Account Option is suitable
given your investment objectives.

Systematic Investment

(periodic premium reallocation programs)

Only the

Automatic Rebalancing. The 3-, 5- and 7-Year Fixed

DCA+ ($15,000 contract minimum)

Investment

Account Options are not available for Automatic

_______ % 6-month

Division(s) and

Rebalancing.

the 1-Year Fixed

_______ % 12-month

Frequency:

Account Option

If DCA+ is selected, you must allocate Designated

(subject to

Monthly

Quarterly

Semiannually

Annually

Option(s) using Systematic Investment Form

availability) as

Start Date (mm/dd/yyyy) ___________________________

(V5385).

selected in the

Note: If no date is selected, the program will begin

Premium

DCA+ provides an automatic monthly transfer to the

one month/quarter/half-year/year (depending on the

Allocation

selected Investment Division(s) so the entire amount

frequency you selected) from the date Jackson applies

section will

invested in this program, plus earnings, will be

the first premium payment. If no frequency is selected, the

participate in

transferred by the end of the DCA+ term selected. If

Automatic

frequency will be annual. No transfers will be made on

selected, the total number of elections in the Premium

Rebalancing.

days 29, 30 or 31, unless set up on annual frequency.

Allocation section may not exceed 17.

Capital Protection Program

Yes

(If no selection is made, Jackson 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 pages 5 and 6.

Telephone and Electronic Transfers Authorization

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)
Producer/Representative subject to Jackson's administrative procedures. This authorization is not extended to
Authorized Callers.

Yes

Do you authorize these types of transfers?

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, not
withstanding 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 Nebraska, New Hampshire and North Dakota and to "
Yes" for residents of all other states.

VDA 630 10/10

Page 6 of 9

V630 10/10

LONG-TERM SMART

Electronic Delivery Authorization

I agree to receive documents electronically:

Check the

ALL DOCUMENTS

boxes next to

the types of

Quarterly statements

Prospectuses and prospectus supplements

documents

you wish to

Periodic and immediate confirmation statements

Proxy and other voting materials

receive

Annual and Semi-Annual reports

Other Contract-related correspondence

electronically.
If an email

This consent will continue unless and until revoked and will cover delivery to you in the form of a compact disc, by

address is

provided, but

email or by notice to you of a document's availability on Jackson's website. Certain types of correspondence may

no document

continue to be delivered by the United States Postal Service for compliance reasons. Registration on Jackson's

type is

website (www.jackson.com) is required for electronic delivery of Contract-related correspondence.

selected, the

selection will

My email address is:_________________________________________. I (We) will notify the company of any new

default to " All

email address.

Documents."

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 email 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.

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 email address. Also let
Jackson know if that email address changes. We may need to notify you of a document's availability through email.
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
email 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.

Authorized Callers

If you want to

First Name

Middle Name

Last Name

authorize an
individual
other than

your

Social Security/Tax I.D. Number

Date of Birth(mm/dd/yyyy)

Producer/Rep

to receive

Contract

information via

First Name

Middle Name

Last Name

telephone,

please list that

individual's

information

Social Security/Tax I.D. Number

Date of Birth(mm/dd/yyyy)

here.

VDA 630 10/10

Page 7 of 9

V630 10/10

LONG-TERM SMART

Notice to Applicant

ARKANSAS, COLORADO, KENTUCKY, MAINE, NEW

Regulatory Agencies.

MEXICO, OHIO, PENNSYLVANIA, AND WEST VIRGINIA

DISTRICT OF COLUMBIA RESIDENTS, PLEASE NOTE:

RESIDENTS, PLEASE NOTE: Any person who

WARNING: It is a crime to provide false or misleading

knowingly, and with intent to defraud any insurance

information to an insurer for the purpose of defrauding

company or other person, files an application for

the insurer or any other person. Penalties include

insurance or statement of claim containing any

imprisonment and/or fines. In addition, an insurer may

materially false information or conceals for the

deny insurance benefits, if false information materially

purpose of misleading, information concerning any

related to a claim was provided by the applicant.

fact material thereto, commits a fraudulent

NEW JERSEY RESIDENTS, PLEASE NOTE: Any person

insurance act, which is a crime and subjects such

who includes any false or misleading information on an

person to criminal and civil penalties.

application for an insurance policy is subject to criminal

In COLORADO, any insurance company, or agent of an

and civil penalties.

insurance company, who knowingly provides false,

LOUISIANA AND RHODE ISLAND RESIDENTS, PLEASE

incomplete, or misleading facts or information to a

NOTE: Any person who knowingly presents a false or

policyholder or claimant for the purpose of defrauding,

fraudulent claim for payment of a loss or benefit or

or attempting to defraud, the policyholder or claimant

knowingly presents false information in an application

with regard to a settlement or award payable from

for insurance is guilty of a crime and may be subject to

insurance proceeds, shall be reported to the Colorado

fines and confinement in prison.

Division of Insurance within the Department of

Client Acknowledgements

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 the Contract's Fixed Account Minimum Interest Rate will be redetermined each Redetermination
Date. The redetermined rate, which may be higher or lower than the Initial Fixed Account Minimum Interest Rate, will
apply for that entire Redetermination Period.

8. 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.

9. I (We) certify that the age of the Owner and any Joint Owner, primary spousal Beneficiary, Annuitant, Joint
Annuitant, or Contingent Annuitant, if applicable, stated in this application are true and correctly recorded.

It is required

Owner's Signature

Date Signed (mm/dd/yyyy) State where signed

for Good Order

that all

applicable

Owner's Title (required if owned by an Entity)

parties to the

Contract sign
here.

Joint Owner's Signature

Date Signed(mm/dd/yyyy) State where signed

Annuitant's Signature (if other than Owner)

Date Signed (mm/dd/yyyy) State where signed

Joint Annuitant's Signature (if other than Joint Owner)

Date Signed(mm/dd/yyyy) State where signed

VDA 630 10/10

Page 8 of 9

V630 10/10

LONG-TERM SMART

Producer/Representative Acknowledgements

Complete this

certification

I certify that:

regarding

I did not use sales material(s) during the presentation of this Jackson product to the applicant.

sales material

section only if:

I used only Jackson-approved sales material(s) during the presentation of this Jackson product to the applicant.

Your client

In addition, copies of all approved sales material(s) used during the presentation were left with the applicant.

has other
existing

By signing this form, I certify that:

policies or

1. I am authorized and qualified to discuss the Contract herein applied for.

annuity

2. I have fully explained the Contract to the client, including Contract restrictions and charges and I believe this

contracts

transaction is suitable given the client's financial situation and needs.

AND

3. The Producer/Representative's Certification Regarding Sales Material has been answered correctly.

Will be either

4. I have read Jackson's Position With Respect to the Acceptability of Replacements (XADV5790) and ensure that

terminating

this replacement (if applicable) is consistent with that position.

any of those

5. The applicant's Statement Regarding Existing Policies or Annuity Contracts has been answered correctly to the

existing

best of my knowledge and belief.

policies or

6. The applicant's statement as to whether or not an existing life insurance policy or annuity contract is being

using the

replaced is true and accurate to the best of my knowledge and belief.

funds from

existing

7. I have complied with requirements for disclosures and/or replacements as necessary.

policies to

fund this new

Contract.

Jackson Prod./Rep. No.

Producer/Representative Signature

Date Signed (mm/dd/yyyy)

First Name

Middle Name

Last Name

Broker/Dealer Name

Program Options

Program

Options Note:
Contact your

home office

Address

(number and street)

City

State ZIP Code

for program
information. If
no option is

indicated, the

Email Address

Business Telephone No. (including area code)

Percentage

designated

(

)

default will be

used.

It is required

If more than one Producer/Representative is participating in a Program Option on this case, please provide all

for Good

Producer/Representative names, Jackson Producer/Representative numbers and percentages for each (totaling 100%).

Order that all
Producer/Rep

numbers be

Producer/Representative Name

Jackson Producer/Representative No.

Percentage

supplied.

Producer/Representative Name

Jackson Producer/Representative No.

Percentage

Not FDIC/NCUA Insured Not Bank/CU guaranteed May lose value

Not a deposit Not insured by any federal agency

VDA 630 10/10

Page 9 of 9

V630 10/10