EX-5.(E) 2 e31128ex5e.txt FORM OF JNL INDIVIDUAL APPLICATION Exhibit 5.(e) [Jefferson National Life Insurance Company [LOGO OMITTED] Regular Delivery: P.O. Box 36750, Louisville, KY 40233 Overnight: 9920 Corporate Campus Drive, Louisville, KY 40223 P: 866.667.0561 F: 866.667.0563] -------------------------------------------------------------------------------- [MONUMENT ADVISOR, A DEFERRED VARIABLE ANNUITY] Owner is (check one): |_| Individual |_| Trust* |_| CRT* |_| Corporation* |_| Other* __________ * Non-natural contract owners must accompany application with additional form: JNL-6000 Due Diligence Supplement.
------------------------------------------------------------------------------------------------------------------------------------ 1A. PRIMARY OWNER 1B. JOINT OWNER (if applicable) ------------------------------------------------------------------------------------------------------------------------------------ Name (first, mi, last) Name (first, mi, last) ------------------------------------------------------------------------------------------------------------------------------------ Street Address Street Address ------------------------------------------------------------------------------------------------------------------------------------ Address Cont'd Address Cont'd ---------------------------------------------------------------------------------------------------------------------------------- City State Zip City State Zip ------------------------------------------------------------------------------------------------------------------------------------ SS#/Tax ID# Phone SS#/Tax ID# Phone ------------------------------------------------------------------------------------------------------------------------------------ Birth Date (mo, day, yr) |_| Male |_| Female Birth Date (mo, day, yr) |_| Male |_| Female ------------------------------------------------------------------------------------------------------------------------------------ 2A. ANNUITANT (if not Owner) 2B. JOINT ANNUITANT (if applicable) ------------------------------------------------------------------------------------------------------------------------------------ Name (first, mi, last) Name (first, mi, last) ------------------------------------------------------------------------------------------------------------------------------------ Street Address Street Address ------------------------------------------------------------------------------------------------------------------------------------ City State Zip City State Zip ------------------------------------------------------------------------------------------------------------------------------------ SS#/Tax ID# Phone SS#/Tax ID# Phone ------------------------------------------------------------------------------------------------------------------------------------ Birth Date (mo, day, yr) |_| Male |_| Female Birth Date (mo, day, yr) |_| Male |_| Female ------------------------------------------------------------------------------------------------------------------------------------ 3A. PRIMARY BENEFICIARIES 3B. CONTINGENT BENEFICIARIES ------------------------------------------------------------------------------------------------------------------------------------ Name #1 (first, mi, last) Relationship Name #1 (first, mi, last) Relationship ------------------------------------------------------------------------------------------------------------------------------------ SS#/Tax ID# Birth Date (mo, day, yr) Percentage SS#/Tax ID# Birth Date (mo, day, yr) Percentage ------------------------------------------------------------------------------------------------------------------------------------ Name #2 (first, mi, last) Relationship Name #2 (first, mi, last) Relationship ------------------------------------------------------------------------------------------------------------------------------------ SS#/Tax ID# Birth Date (mo, day, yr) Percentage SS#/Tax ID# Birth Date (mo, day, yr) Percentage ------------------------------------------------------------------------------------------------------------------------------------ |_| Check here to include additional beneficiaries |_| Check here to include additional beneficiaries on separate page. on separate page. ------------------------------------------------------------------------------------------------------------------------------------ 4. ELECTRONIC ACCESS ------------------------------------------------------------------------------------------------------------------------------------ As Primary Owner of the Contract, I hereby agree to access all information relating to my Contract electronically, through my Jefferson National online account which shall be established upon issuance of my contract. I can access my contract through the Jefferson National website, www.jeffnat.com. I agree to visit the Jefferson National website periodically to review all documents relating to my Contract. I agree to keep Jefferson National apprised of any changes to my e-mail address shown below. I agree to maintain the password security of my online account and understand that I will be responsible for all orders, data, information or requests using my password. If I suspect there is unauthorized use of my password, I agree to notify Jefferson National immediately. The e-mail address provided will only be used for communication related to my Contract with Jefferson National and shall not be used for any other purposes. Except as permitted by law, Jefferson National does not transfer customer data to unaffiliated third parties. Primary Owner e-mail address (required)___________________________________ If you would also like to receive a copy of the following items via US Mail, please check the appropriate box. Please Note: These paper documents are in addition to, and not a replacement for, the electronic version of the documents that will be held in your online account. While electronic notification is immediate, mail times may be longer. ______ [Statements ______ Original Policy ______ Product Prospectus/Supplements ______ Financial Transactions ______ Investment Portfolio Prospectuses ______ Non Financial Transactions] ------------------------------------------------------------------------------------------------------------------------------------
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------------------------------------------------------------------------------------------------------------------------------------ 5. PURCHASE PAYMENT/PLAN TYPE ([$25,000 minimum]. Fill out Section A or Section B.) ------------------------------------------------------------------------------------------------------------------------------------ A. Nonqualified: Estimated Amount: $____________________________. |_| 1035 Exchange (Requires Form VA121: Authorization to Transfer Funds and state replacement forms.) OR -------------------- ------------------------------------------------------------------------------------------------------- |_| New Money Amount: $ ___________________________ paid by: |_| Enclosed Check (Payable to: Jefferson National Life Insurance Company) |_| EFT Bank Routing/ABA # __________________ Account # _________________________ |_| Other (Requires Form VA 121: Authorization to Transfer Funds and state replacement forms.) ------------------------------------------------------------------------------------------------------------------------------------ B. Qualified: |_| Transfer Estimated Amount $_____________________________ |_| Rollover (Requires Form VA121 Authorization to Transfer Funds and state replacement forms.) OR -------------------- ------------------------------------------------------------------------------------------------------- |_| New Money Amount: $ _____________________ paid by: |_| Enclosed Check (Payable to: Jefferson National Life Insurance Company) |_| EFT Bank Routing/ABA # __________________ Account # __________________________ |_| Other (Requires Form VA 121: Authorization to Transfer Funds and state replacement forms.) ------------------------------------------------------------------------------------------------------------------------------------ Qualified Plan Type: |_| IRA |_| Roth IRA |_| SEP IRA |_| Simple IRA |_| Other ______________________________________ IRA Contribution for Tax Yr: ___________________ ------------------------------------------------------------------------------------------------------------------------------------ [6. DEATH BENEFIT OPTION (select one only)] ------------------------------------------------------------------------------------------------------------------------------------ |_| [Return of Premium] |_| [Return of Contract Value] |_| [Annual Step-up] |_| [Annual Roll-up] ------------------------------------------------------------------------------------------------------------------------------------ 7. INVESTMENT OPTIONS (Please see Appendix A for a complete listing of Investment Options.) ------------------------------------------------------------------------------------------------------------------------------------ You can choose to allocate your initial contribution by completing Appendix A. Alternatively, if you wish to allocate your initial contribution solely to a money market, please indicate below. You may change this allocation after your Contract is issued. __________ [100% PIMCO Money Market] _________ [100% Rydex US Gov't Money Market] ------------------------------------------------------------------------------------------------------------------------------------
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------------------------------------------------------------------------------------------------------------------------------------ 8. INVESTMENT ADVISOR AUTHORIZATION (To be signed by Investment Advisor, if any.) ------------------------------------------------------------------------------------------------------------------------------------ Special Notes: o If you are an agent and will be appointed by Jefferson National, you certify, by signing this form, that you have asked all the questions on the application and correctly recorded the answers of the proposed Owner/annuitant. You attest that you have presented to the Company all pertinent facts. You must complete sections 7A and 7B. o If you are not being appointed, in addition to completing Section 7A, you must also complete the Advisor Authorization Agreement (VA 122 Advisor Authorization Agreement). o You MUST complete section 8D (investment Advisor Replacement Question). o Enclose Form VA-125 Suitability signed by the Contract Owner. ------------------------------------------------------------------------------------------------------------------------------------ 8A. INVESTMENT ADVISOR (If you would like trading authorization and are not completing Section 7B., please complete VA-122 Advisor Authorization Agreement.) ------------------------------------------------------------------------------------------------------------------------------------ Name of Investment Advisor: Jefferson National Advisor ID: (if known) ------------------------------------------------------------------------------------------------------------------------------------ Name of Advisory Firm: Jefferson National Firm ID: (if known) ------------------------------------------------------------------------------------------------------------------------------------ Address: ------------------------------------------------------------------------------------------------------------------------------------ Phone: Fax: ------------------------------------------------------------------------------------------------------------------------------------ Email: (required) Tax ID#/SS#: ------------------------------------------------------------------------------------------------------------------------------------ Advisor Signature: Date: ------------------------------------------------------------------------------------------------------------------------------------ 8B. BROKER DEALER INFORMATION: (Please complete this section if you are currently associated with a Broker Dealer and will be appointed with Jefferson National.) ------------------------------------------------------------------------------------------------------------------------------------ Broker Dealer Name: Contact Name: ------------------------------------------------------------------------------------------------------------------------------------ Address: Phone: ------------------------------------------------------------------------------------------------------------------------------------ 8C. THIRD PARTY INVESTMENT ADVISOR: (Please complete this section and VA-122 Advisor Authorization Agreement for any additional money management and trading authorization.) ------------------------------------------------------------------------------------------------------------------------------------ Third Party Investment Firm: Jefferson National Advisor ID: (if known) ------------------------------------------------------------------------------------------------------------------------------------ Contact Name at Firm: Email: ------------------------------------------------------------------------------------------------------------------------------------ Address: ------------------------------------------------------------------------------------------------------------------------------------ Phone: Fax: Tax ID#/SS#: ------------------------------------------------------------------------------------------------------------------------------------ Authorized Signature: Date: ------------------------------------------------------------------------------------------------------------------------------------ |_| Check here to include additional Advisors on a separate page. ------------------------------------------------------------------------------------------------------------------------------------ 8D. Investment Advisor Replacement Question (to be answered by Investment Advisors) ------------------------------------------------------------------------------------------------------------------------------------
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------------------------------------------------------------------------------------------------------------------------------------ Do you, as advisor/agent, have reason to believe the product applied for will replace existing annuities or life insurance? |_| Yes* |_| No Are there any life insurance policies or annuity contracts owned by or on the life of the owner or the annuitant? |_| Yes |_| No ------------------------------------------------------------------------------------------------------------------------------------ 9. FRAUD WARNINGS ------------------------------------------------------------------------------------------------------------------------------------ NAIC Model Fraud Statement: 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. AZ, AK, CO, KY, ME, NM, OH, OK, PA, TN: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits. NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. FL: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. ------------------------------------------------------------------------------------------------------------------------------------ 10. OWNER STATEMENT ------------------------------------------------------------------------------------------------------------------------------------ All statements made on all pages of this application are true to the best of my knowledge and belief and I agree to all terms and conditions as stated herein. I also agree that this application may become a part of my annuity contract. I further verify my understanding that all payments and values provided by the contract, when based on the investment experience of the variable account, are variable and are not guaranteed as to dollar amount. I acknowledge receipt of a current prospectus. Under penalty of perjury, I certify that the social security or taxpayer identification number is correct as it appears in this application. I understand that Jefferson National may, from time to time, sponsor conferences or otherwise remunerate broker/dealers or other third parties for marketing or other services. I understand that if a financial advisor affiliated with a broker/dealer assisted me in the purchase of this variable annuity, he/she may be acting as an agent of Jefferson National. ------------------------------------------------------------------ NOT FDIC/NCUA INSURED MAY LOSE VALUE NO BANK GUARANTEE ------------------------------------------------------------------ NO FDIC NO BANK NOT A DEPOSIT NOT INSURED BY ANY FEDERAL GOVERNMENT AGENCY ------------------------------------------------------------------ Are there any life insurance policies or annuity contracts owned by or on the life of the owner or the annuitant? |_| Yes |_| No Will the proposed contract replace any existing annuity or insurance contract? |_| Yes Replacement requirements must be followed. (All transfers and/or exchanges are considered replacements.) |_| No ------------------------------------------------------------------------------------------------------------------------------------ Signature of Owner: Signature of Joint Owner: ------------------------------------------------------------------------------------------------------------------------------------ Date: Date: ------------------------------------------------------------------------------------------------------------------------------------ SPECIAL REMARKS: ------------------------------------------------------------------------------------------------------------------------------------ FOR HOME OFFICE USE ------------------------------------------------------------------------------------------------------------------------------------
JNL-6005-4 Page 4 of 7 Jefferson National Life Insurance Company [LOGO OMITTED] Regular Delivery: P.O. Box 36750, Louisville, KY 40233 Overnight: 9920 Corporate Campus Drive, Louisville, KY 40223 P: 866.667.0561 F: 866.667.0563] APPENDIX A. INVESTMENT OPTIONS (USE WHOLE PERCENTAGES TO INDICATE THE INVESTMENT ALLOCATION DESIRED. PERCENTAGES ALLOCATED FOR ALL PORTFOLIOS MUST EQUAL 100%.)
--------------------------------------------------------------- --------------------------------------------------------------- [BALANCED: Ultrashort Bond --------------- Conservative Allocation ----------------------- __________PIMCO Short Term Bond __________Federated Market Opportunity World Bond __________Rydex Essential Conservative ---------- Moderate Allocation __________PIMCO Foreign Bond ------------------- __________PIMCO Global Bond __________Van Eck Worldwide Bond __________American Century Balanced __________Federated Capital Income INTERNATIONAL STOCK: __________Janus Aspen Balanced __________JNF Chicago Equity Partners Balanced Diversified Emerging Markets __________Lord Abbett America's Value ---------------------------- __________PIMCO All Asset __________Rydex CLS AdvisorOne Clermont __________Lazard Emerging Markets __________Rydex Essential Moderate __________Pioneer Emerging Markets __________Van Eck Worldwide Emerging Markets BOND: Foreign Large Blend Emerging Markets Bond ------------------- --------------------- __________Lazard International Equity __________PIMCO Emerging Markets Bond __________Pioneer International Value High Yield Bond Foreign Large Growth --------------- -------------------- __________AIM High Yield Bond __________American Century International __________Federated High Income __________Federated International Equity __________Legg Mason Global High Yield Bond __________Janus Aspen International Growth __________Lehman Brothers High Income Bond __________PIMCO High Yield Bond Foreign Large Value __________Pioneer Global High Yield Bond ------------------- __________Pioneer High Yield Bond __________Dreyfus International Value Inflation-Protected Bond ------------------------ World Stock ----------- __________American Century Inflation Protection Bond __________PIMCO Real Return Bond __________Janus Aspen Worldwide Growth Intermediate-Term Bond LARGE CAP STOCK: ---------------------- Large Blend __________PIMCO Total Return Bond ----------- Long Government Bond __________AIM Basic Value -------------------- __________AIM Core Equity __________Legg Mason Government Bond __________Janus Aspen INTECH Risk-Managed Core __________PIMCO Long Term US Government Bond __________Legg Mason Fundamental __________Neuberger Berman Socially Responsive Multisector Bond __________PIMCO StocksPLUS Total Return ---------------- __________Pioneer Fund __________Rydex CLS AdvisorOne Amerigo __________Legg Mason Strategic Bond __________Rydex Essential Aggressive __________Pioneer Strategic Income Bond Short-Term Bond --------------- __________Lehman Brothers Short Duration Bond __________PIMCO Low Duration Bond __________T. Rowe Price Limited Term Bond --------------------------------------------------------------- ---------------------------------------------------------------
JNL-6005-4 Page 5 of 7 Jefferson National Life Insurance Company [LOGO OMITTED] Regular Delivery: P.O. Box 36750, Louisville, KY 40233 Overnight: 9920 Corporate Campus Drive, Louisville, KY 40223 P: 866.667.0561 F: 866.667.0563] APPENDIX A. INVESTMENT OPTIONS (USE WHOLE PERCENTAGES TO INDICATE THE INVESTMENT ALLOCATION DESIRED. PERCENTAGES ALLOCATED FOR ALL PORTFOLIOS MUST EQUAL 100%.)
--------------------------------------------------------------- --------------------------------------------------------------- LARGE CAP STOCK: Mid-Cap Growth -------------- Large Growth ------------ __________Alger Mid Cap Growth __________American Century Vista __________Alger American Growth __________Federated Kaufman __________Alger American Leveraged All Cap __________Janus Aspen Mid Cap Growth __________American Century Ultra __________Neuberger Berman Mid Cap Growth __________Dreyfus Socially Responsible Growth __________Wells Fargo Advantage Discovery __________Janus Aspen Forty __________Janus Aspen Growth & Income Mid-Cap Value __________Janus Aspen INTECH Risk-Managed Growth ------------- __________Janus Aspen Large Cap Growth __________Legg Mason Aggressive Growth __________Alliance Bernstein Small Mid Cap Value __________Legg Mason Capital & Income __________Janus Aspen Mid Cap Value __________Legg Mason Large Cap Growth __________Neuberger Berman Regency __________T. Rowe Price Blue Chip Growth __________Pioneer Mid Cap Value Large Value Small Blend ----------- ----------- __________Alliance Bernstein Growth & Income __________Dreyfus Small Cap Stock Index __________American Century Income & Growth __________Lazard Small Cap __________American Century Large Company Value __________Pioneer Small Cap Value __________American Century Value __________Royce Capital Fund Micro-Cap __________Lazard US Strategic Equity __________Royce Capital Fund Small-Cap __________Lord Abbett Growth & Income __________Third Avenue Value __________Pioneer Cullen Value __________Pioneer Equity Income Small Growth __________T. Rowe Price Equity Income ------------ INDEX FUNDS: __________Alger American Small Cap __________Neuberger Berman Fasciano Low Cost Index Funds -------------------- Small Value __________Dreyfus Stock Index ----------- __________Nationwide Bond Index* __________Nationwide International Index* __________Janus Aspen Small Company Value __________Nationwide Mid Cap Index* __________Nationwide S&P 500 Index* SPECIALTY STOCK: __________Nationwide Small Cap Index* Long-Short *These select funds also have a transaction fee ranging from ---------- $19.99 to $49.99 per transaction, depending on the number of transactions per year. See the prospectus for details. __________Rydex Hedged Equity __________Van Eck Worldwide Absolute Return MONEY MARKET: __________PIMCO Money Market Specialty-Financial __________Rydex US Government Money Market ------------------- SMALL/MID CAP STOCK: __________AIM Financial Services Mid-Cap Blend Specialty-Health ------------- ---------------- __________AIM Mid Cap Core Equity __________AIM Global Health Care __________JNF Chicago Equity Partners Equity __________Janus Aspen Global Life Sciences __________Rydex Absolute Return Strategies __________T. Rowe Price Health Sciences __________Wells Fargo Advantage Opportunity Specialty-Natural Resources --------------------------- __________Credit Suisse Commodity Return Strategy __________PIMCO Commodity RealReturn __________Van Eck Worldwide Hard Assets --------------------------------------------------------------- ---------------------------------------------------------------
JNL-6005-4 Page 6 of 7 Jefferson National Life Insurance Company [LOGO OMITTED] Regular Delivery: P.O. Box 36750, Louisville, KY 40233 Overnight: 9920 Corporate Campus Drive, Louisville, KY 40223 P: 866.667.0561 F: 866.667.0563] APPENDIX A. INVESTMENT OPTIONS (USE WHOLE PERCENTAGES TO INDICATE THE INVESTMENT ALLOCATION DESIRED. PERCENTAGES ALLOCATED FOR ALL PORTFOLIOS MUST EQUAL 100%.)
--------------------------------------------------------------- --------------------------------------------------------------- SPECIALITY STOCK Cont'd: __________Rydex Russell 2000 1.5x Strategy __________Rydex Russell 2000 2x Strategy Specialty - Precious Metals __________Rydex S&P 500 2x Strategy --------------------------- __________Rydex Sector Rotation __________Rydex Small Cap Growth __________Rydex Precious Metals __________Rydex Small Cap Value __________Rydex Strengthening Dollar 2x Strategy Specialty - Real Estate __________Rydex Technology ----------------------- __________Rydex Telecommunications __________Rydex Transportation __________AIM Global Real Estate __________Rydex Utilities __________PIMCO RealEstateRealReturn Strategy __________Rydex Weakening Dollar 2x Strategy] __________Van Eck Worldwide Real Estate Specialty - Technology ---------------------- __________AIM Technology __________Seligman Communications & Information __________Seligman Global Technology ACTIVELY TRADED FUNDS: __________Direxion Dynamic High Yield Bond __________Rydex Banking __________Rydex Basic Materials __________Rydex Biotechnology __________Rydex Commodities Strategy __________Rydex Consumer Products __________Rydex Dow 2x Strategy __________Rydex Electronics __________Rydex Energy __________Rydex Energy Services __________Rydex Europe 1.25x Strategy __________Rydex Financial Services __________Rydex Gov't Long Bond 1.2x Strategy __________Rydex Health Care __________Rydex Inverse Government Long Bond __________Rydex Internet __________Rydex Inverse Dow 2x Strategy __________Rydex Inverse Russell 2000 Strategy __________Rydex Inverse Mid Cap Strategy __________Rydex Inverse OTC Strategy __________Rydex Inverse S&P 500 Strategy __________Rydex Japan 1.25x Strategy __________Rydex Large Cap Growth __________Rydex Large Cap Value __________Rydex Leisure __________Rydex Mid Cap 1.5 Strategy __________Rydex Mid Cap Growth __________Rydex Mid Cap Value __________Rydex Multi Cap Core Equity __________Rydex Nova __________Rydex OTC __________Rydex OTC 2x Strategy __________Rydex Real Estate __________Rydex Retailing --------------------------------------------------------------- ---------------------------------------------------------------
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