EX-99.(5)(A) 6 a21820exv99wx5yxay.htm EXHIBIT 5A exv99wx5yxay
 

(FORM)
Pacific Life Insurance Company PACIFIC VOYAGES P.O. Box 7187 • Pasadena, CA 91109-7187 www.PacificLife.com • (800) 722-2333 Variable Annuity Application Call (800) 722-2333 for assistance. 1. ANNUITANT(S) Must be an individual. Check product guidelines for maximum issue age. Name (First, Middle, Last) Birth Date (mo/day/yr) Sex John R. Doe 01/01/1970 M 3M M F Mailing 555 Main Street Address City, Anytown, USA 12345 State, ZIP SSN ###-##-#### Residential Address (if different than mailing address) City, State, ZIP Solicited at: State Complete this box for custodial-owned qualified contracts only. Will not be valid for any other contract types. Information put here will be used for contract and agent appointment purposes. ADDITIONAL ANNUITANT Not applicable for qualified contracts. Check One: M 3Joint M Contingent Name (First, Middle, Last) Birth Date (mo/day/yr) Sex Jane A. Doe 01/01/1970 M M M 3F Mailing 555 Main Street Address City, Anytown, USA 12345 State, ZIP SSN ###-##-#### Residential Address (if different than mailing address) City, State, ZIP 2. OWNER(S) If annuitant and owner are the same, do not complete this section. Check product guidelines for maximum issue age. For contracts with an owner that is a 401(a), 401(k) or Keogh/HR10 plan, also complete the Qualified Plan Disclosure form. For individual-owned or trust-owned Inherited IRA or Inherited 403(b) contracts, also complete the Inherited IRA or Inherited TSA/403(b) Certification form. For nonqualified contracts, if the owner is a non-natural person or corporation, also complete the Non-Natural or Corporate-Owned Disclosure Statement. If the owner is a trust, also complete the Trustee Certification and Disclosure form. Name (First, Middle, Last) Birth Date (mo/day/yr) Sex M M M F Mailing Address City, State, ZIP SSN/TIN Residential Address (if different than mailing address) City, State, ZIP ADDITIONAL OWNER Not applicable for qualified contracts. Check One: M Joint M Contingent Name (First, Middle, Last) Birth Date (mo/day/yr) Sex M M M F Mailing Address City, State, ZIP SSN Residential Address (if different than mailing address) City, State, ZIP 3. DEATH BENEFIT COVERAGE M Stepped-Up Death Benefit Annuitant(s) must not be over age 75 at issue. If the stepped-up death benefit I have selected cannot be added to the contract due to age restrictions or state availability, I understand that the contract will be issued without the stepped-up death benefit rider. 25-1130 08/06 *4004-6A1*

 

 

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4 . TELEPHONE/ELECTRONIC AUTHORIZATIONS TELEPHONE/ELECTRONIC TRANSACTION AUTHORIZATION As the owner, I will receive this privilege automatically. If a contract has joint owners, each owner may individually make telephone and/or electronic requests. By checking “yes,” I am also authorizing and directing Pacific Life to act on telephone or electronic instructions from any other person(s) who can furnish proper identification. Pacific Life will use reasonable procedures to confirm that these instructions are authorized and genuine. As long as these procedures are followed, Pacific Life and its affiliates and their directors, trustees, officers, employees, representatives and/or agents, will be held harmless for any claim, liability, loss or cost. 3 CHECK M Yes IF YES ELECTRONIC DELIVERY AUTHORIZATION By providing my e-mail address below, I authorize Pacific Life to provide my statements, prospectuses and other information (documents) electronically instead of sending paper copies of these documents by U.S. mail. I will continue to receive paper copies of annual statements. I understand that I must have internet access (my internet provider may charge for internet access) and I must provide my e-mail address below to use this service. FOR EVEN FASTER JDoe@aol.com DELIVERY E-mail address: 5. BENEFICIARIES If a beneficiary classification is not indicated, the class for that beneficiary will be primary. Multiple beneficiaries will share the death benefit equally, unless otherwise specified. For non-individually owned custodially held IRAs, 457 and qualified plans, if no beneficiary is listed, the beneficiary will default to the owner listed on the application. Unless otherwise indicated, proceeds will be divided equally. Use Special Requests section to provide additional beneficiary information. Name (First, Middle, Last) M 3Primary Relationship SSN/TIN Percentage Mary S. Doe M Contingent Daughter ###-##-#### 100 % Name (First, Middle, Last) M Primary Relationship SSN/TIN Percentage M Contingent % 6. CONTRACT TYPE Select ONE. M 3Non-Qualified M SIMPLE IRA(1) M Roth IRA M 401(a)(3) M 457(b) — gov’t. entity M Keogh/HR10(3)M IRA M SEP-IRA M TSA/403(b)(2) M 401(k)(3) M 457(b) — 501(c) tax exempt (1)Complete SIMPLE IRA Employer Information form. (2)Complete TSA Certification form. (3)Complete Qualified Plan Disclosure form. 7. INITIAL PURCHASE PAYMENT Make check payable to Pacific Life Insurance Company. 7A. NON-QUALIFIED CONTRACT PAYMENT TYPE 7B. QUALIFIED CONTRACT PAYMENT TYPE Indicate type of initial Indicate type of initial payment. payment. If no year is indicated, contribution defaults to current tax year. M 1035 exchange/estimated transfer . . . . . . . .         . . .$5,000 M Transfer . . . . . . . . $ M 3Amount enclosed . . . . . . . . . .         . . . . . . . . . . . . . .$ M Rollover . . . . . . . . $ M Contribution . . . .         . $ for tax year 8. REPLACEMENT Will the purchase of this annuity result in the replacement, termination or change in value of any existing life insurance or MUST M Yes M 3No CHECK annuity in this or any other company? ONE If yes, provide the information below and attach any required state replacement and/or 1035 exchange/transfer forms. Insurance Company Name(s) Contract Number(s) Contract Type Being Replaced M Life Insurance M Fixed Annuity M Variable Annuity 9. AVAILABLE OPTIONS Subject to state availability. To qualify for Lifetime Income Access Plus, Income Access, GIA Plus or GPA(5)rider benefits, the entire contract value must stay invested in an approved asset allocation program established and maintained by Pacific Life for the riders. M Lifetime Income Access Plus Annuitant(s) must not be over age 85 at issue. M GPA(5)Annuitant(s) must not be over age 85 at issue, which m ust be at least ten years prior to the annuity date. M Income Access Annuitant(s) must not be over age 85 at issue. M EEG Annuitant(s) must not be over age 75 at issue. M GIA Plus Annuitant(s) must not be over age 80 at issue. If any rider I have selected within this section cannot be added to the contract due to age restrictions or state availability, I understand that the contract will be issued without the rider(s). 25-1130 08/06 *4004-6A2*

 

 

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10. SPECIAL REQUESTS If additional space is needed, atttach letter signed and dated by the owner(s). 11. ALLOCATION OPTIONS Use whole percentages only. Allocations must total 100%. Complete Transfers and Allocations form for dollar cost averaging and rebalancing. Manager: Investment Options Manager: Investment Options AllianceBernstein % International Value Neuberger Berman % Fasciano Small Equity Batterymarch 10 % International Small-Cap NFJ % Small-Cap Value Capital Guardian % Diversified Research Oppenheimer 20 % Multi-Strategy % Equity % Main Street(®)Core % Emerging Markets Capital Research % American Funds Growth-Income % American Funds Growth PIMCO % Managed Bond % Inflation Managed Columbia % Technology Pacific Life % Money Market Goldman Sachs % Short Duration Bond % High Yield Bond % Concentrated Growth 20 % DCA Plus Fixed Option with a Guarantee Term of JPMorgan % Diversified Bond 12 months Indicate percentage of premium payment to be Janus % Growth LT allocated to the DCA Plus Fixed Option and complete % Focused 30 the DCA section of the Transfers and Allocations form. 10 Jennison % Health Sciences Salomon Brothers % Large-Cap Value Lazard % Mid-Cap Value Van Kampen % Comstock % Mid-Cap Growth Loomis Sayles % Large-Cap Growth % Real Estate MFS % Capital Opportunities Vaughan Nelson 40 % VN Small-Cap Value % International Large-Cap Mercury % Equity Index 100 % Small-Cap Index MUST TOTAL 100% 25-1130 08/06 *4004-6A3*

 

 

(FORM)
12. STATEMENT OF OWNER(S) I understand that federal law requires all financial institutions to obtain the name, residential address, date of birth and Social Security or taxpayer identification number, and any other information necessary to sufficiently verify the identity of each customer. I understand that failure to provide this information could result in the annuity contract not being issued, delayed or unprocessed transactions or annuity contract termination. I, the owner(s), understand that I have applied for an individual flexible premium deferred variable annuity contract (“contract”) issued by Pacific Life Insurance Company (“company”). I received prospectuses for this variable annuity contract. After reviewing my financial background with my agent, I believe this contract will meet my insurable needs and financial objectives. If applicable, I considered the appropriateness of full or partial replacement of any existing life insurance or annuity. I understand the terms and conditions related to a ny optional rider applied for and believe that the rider(s) meet(s) my insurable needs and financial objectives. I UNDERSTAND THAT BENEFITS AND VALUES PROVIDED UNDER THE CONTRACT MAY BE ON A VARIABLE BASIS. AMOUNTS DIRECTED INTO ONE OR MORE VARIABLE INVESTMENT OPTIONS WILL REFLECT THE INVESTMENT EXPERIENCE OF THOSE INVESTMENT OPTIONS. THESE AMOUNTS MAY INCREASE OR DECREASE, AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. I have discussed all fees and charges for this contract with my agent, including withdrawal charges. I understand that if I cancel a contract issued as a result of this application without penalty during the Right to Cancel initial review period, depending upon the state where my contract is issued, it is possible the amount refunded may be less than the initial amount I invested due to the investment experience of my selected investment options. If there are joint owners, the issued contract will be owned by the joint owners as Joint Tenants With Right of Survivorship and not as Tenants in Common. I certify, under penalties of perjury, that I am a U.S. person (including a U.S. resident alien) and that the taxpayer identification number is correct. The following states require insurance companies to provide a fraud warning statement. Please refer to the fraud warning statement for your state as indicated below. Please check for state product availability. Colorado It is unlawful to knowingly provide false, incomplete, misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. 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 Services. Virginia It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. All Other States: 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. SIGN DATE CITY STATE HERE Owner’s Signature Date 01(mo/day/yr) /01/2006 Signed Anytown at: City State U S SIGN DATE HERE Joint Owner’s Signature if applicable Date 01(mo/day/yr) /01/2006 13. AGENT’S STATEMENT Do you have reason to believe that any existing life insurance policy or annuity contract has been (or will be) surrendered, withdrawn from, loaned against, changed or otherwise reduced in value, or replaced in connection with this transaction assuming the contract applied for will be issued? M Yes M 3No If “Yes”, I affirm that I have instructed the applicant to answer “yes” to the replacement question in Section 8 of this application. I have explained to the MUST owner(s) how the annuity will meet their insurable needs and financial objectives. I have discussed the appropriateness of replacement, and followed Pacific CHECK ONE Life’s written replacement guidelines. SIGN HERE Soliciting Agent’s Signature Print Cindy Agent’s Full Name Brown Agent’s Telephone Number Agent’s E-Mail Address Option 213-495-0111 M A M 3B M C Brown oker/Dealer’s Name & Associates or RIA (if applicable) Brokerage Account Number Optional Send completed application as follows: APPLICATIONS WITH PAYMENT: APPLICATIONS WITHOUT PAYMENT: Regular Mail Delivery: P.O. Box 100060, Pasadena, CA 91189-0060 Regular Mail Delivery: P.O. Box 7187, Pasadena, CA 91109-7187 Express Mail Delivery: 1111 S. Arroyo Parkway, Ste. 205, Pasadena, CA 91105 Express Mail Delivery: 1111 S. Arroyo Parkway, Ste. 205, Pasadena, CA 91105 25-1130 08/06 *4004-6A4*