EX-99.(B)(5)(D) 5 c47745_ex99-b5d.txt Exhibit 99(b)(5)(d) JEFFERSON NATIONAL LIFE INSURANCE COMPANY ("THE COMPANY") DALLAS, TEXAS [ATTENTION: VARIABLE ANNUITY NEW BUSINESS P.O. BOX 36750, LOUISVILLE, KY 40233 FAX: 1-866-667-0563 [JEFFERSON NATIONAL LOGO] CHECKS PAYABLE TO: JEFFERSON NATIONAL LIFE INSURANCE COMPANY [_] CHECK HERE TO SEND CONTRACT DIRECTLY TO CLIENT. ----------------------------------------------------------------------------------------------------------------------------------- MONUMENT ADVISOR APPLICATION 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. OWNER 1B. JOINT OWNER (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 ============================== ================================== ============================== =================================== 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 on [_] Check here to include additional beneficiaries on separate page. separate page. ================================================================= ================================================================== 4. PURCHASE PAYMENT/ PLAN TYPE ($25,000 MINIMUM. FILL OUT SECTION A OR SECTION B.) ------------------------------ ------------------------------------------ --------------------------------------------------------- A. NONQUALIFIED: Estimated Amount: $___________________ (REQUIRES FORM VA121: AUTHORIZATION TO TRANSFER FUNDS [_] 1035 Exchange AND STATE REPLACEMENT FORMS.) ----------------------------------------------------------------------------------------------------------------------------------- OR [_] New Money Amount: $ ___________________ paid by: [_] Enclosed Check or [_] EFT BANK ROUTING/ABA # __________________ ACCOUNT # __________________________ ------------------------------ ------------------------------------------ --------------------------------------------------------- B. QUALIFIED: [_] Transfer [_] Rollover Estimated Amount $____________________ (REQUIRES FORM VA121 AUTHORIZATION TO TRANSFER FUNDS AND STATE REPLACEMENT FORMS.) ----------------------------------------------------------------------------------------------------------------------------------- OR [_] New Money Amount: $ ___________________ paid by: [_] Enclosed Check or [_] EFT BANK ROUTING/ABA # __________________ ACCOUNT # __________________________ ----------------------------------------------------------------------------------------------------------------------------------- QUALIFIED PLAN TYPE: [_] IRA [_] Roth IRA [_] SEP IRA [_] Simple IRA [_] Other ________________ IRA Contribution for Tax Yr: ________ ------------------------------ ---------------------------------------------------------------------------------------------------- JNL-6005-3 Page 1 of 5
==================================================================================================================================== 5. INVESTMENT SELECTIONS-- Use whole percentages to indicate the investment allocation desired. Percentages allocated for all portfolios must equal 100%. ------------------------------------------------------------------------------------------------------------------------------------ NEUBERGER BERMAN ADVISERS MGMT TRUST ADVISORONE FUNDS--RYDEX VARIABLE TRUST FEDERATED INSURANCE SERIES (Cont.) ------------------------------------------- ------------------------------------------- -------------------------------------------- ________% CLS AdvisorOne Amerigo ________% Federated Capital Income II ________% Lehman Brothers High Income Bond ________% CLS AdvisorOne Clermont ________% Federated High Income Bond II ________% Lehman Brothers Short Duration ------------------------------------------- ________% Federated International Equity II Bond AIM VARIABLE INSURANCE FUNDS ________% Federated Kaufmann II ________% NB AMT Mid-cap Growth ------------------------------------------- ________% Federated Market Opportunity II ________% NB AMT Partners ________% AIM V.I. Basic Value --------------------------------------------________% NB AMT Regency ________% AIM V.I. Core Equity JANUS ASPEN SERIES--INSTUTIONAL SERIES ________% NB AMT Socially Responsive ________% AIM V.I. High Yield ---------------------------------------------------------------------------------------- ________% AIM V.I. Mid Cap Core Equity ________% Janus Aspen Balanced NORTHERN LIGHTS VARIABLE TRUST ________% AIM V.I. Global Real Estate ________% Janus Aspen Forty -------------------------------------------- ________% AIM V.I. Financial Services ________% Janus Aspen Global Life Sciences ________% JNF Chicago Equity Partners Equity ________% AIM V.I. Global Health Care ________% Janus Aspen Growth and Income ________% JNF Chicago Equity Partners ________% AIM V.I. Technology ________% Janus Aspen International Growth Balanced ------------------------------------------- ________% Janus Aspen Large Cap Growth -------------------------------------------- THE ALGER AMERICAN FUND ________% Janus Aspen Mid Cap Growth PIMCO VARIABLE INSURANCE TRUST (ADMIN CL.) ------------------------------------------- ________% Janus Aspen Mid Cap Value -------------------------------------------- ________% AA Growth ________% Janus Aspen Worldwide Growth ________% PVIT All Asset ________% AA Leveraged AllCap --------------------------------------------________% PVIT CommodityRealReturn Strategy ________% AA MidCap Growth JANUS ASPEN SERIES--SERVICE SHARES ________% PVIT Emerging Markets Bond ________% AA Small Capitalization --------------------------------------------________% PVIT Foreign Bond (US Dollar ------------------------------------------- ________% Janus Aspen INTECH Risk-Managed Hedged) ALLIANCEBERNSTEIN VAR. PRODUCTS SERIES Core ________% PVIT Global Bond (Unhedged) ------------------------------------------- ________% Janus Aspen INTECH Risk-Managed ________% PVIT High Yield ________% AB Growth & Income Growth ________% PVIT Long-Term U.S. Government ________% AB Small/Mid Cap Value ________% Janus Aspen Small Company Value ________% PVIT Low Duration ------------------------------------------- --------------------------------------------________% PVIT Money Market AMERICAN CENTURY VARIABLE PORTFOLIOS LAZARD RETIRMENT SERIES, INC. ________% PVIT RealEstateRealReturn ------------------------------------------- -------------------------------------------- Strategy ________% Amer. Cent. VP Balanced ________% Lazard Retirement Emerging Markets________% PVIT Real Return ________% Amer. Cent. VP Income & Growth ________% Lazard Retirement US Strategic ________% PVIT Short-Term ________% Amer. Cent. VP Inflation Prot. Equity ________% PVIT StockPlus Total Return ________% Amer. Cent. VP International ________% Lazard Ret. International Equity ________% PVIT Total Return ________% Amer. Cent. VP Large Company ________% Lazard Retirement Small Cap -------------------------------------------- Value --------------------------------------------PIONEER VARIABLE CONTRACTS TRUST ________% Amer. Cent. VP Ultra LEGG MASON PARTNERS VAR. PORTFOLIOS -------------------------------------------- ________% Amer. Cent. VP Value --------------------------------------------________% Pioneer Core Bond VCT II ________% Amer. Cent. VP Vista ________% Legg Mason Part. Var. Aggressive ________% Pioneer Cullen Value VCT II ------------------------------------------- Growth ________% Pioneer Emerging Markets VCT II CREDIT SUISSE TRUST ________ Legg Mason Part. Var. Capital and ________% Pioneer Equity Income VCT II ------------------------------------------- Income ________% Pioneer Fund VCT II ________% Credit Suisse Commodity ________% Legg Mason Part. Var. ________% Pioneer Global High Yield VCT II Return Strategy Fundamental Value ________% Pioneer High Yield VCT II ------------------------------------------- ________% Legg Mason Part. Var. Global ________% Pioneer International Value DIREXION INSURANCE TRUST High Yield Bond VCT II ------------------------------------------- ________% Legg Mason Part. Var. ________% Pioneer Mid Cap Value VCT II ________% DireXion Dynamic VP HY Bond Government ________% Pioneer Strategic Income VCT II ------------------------------------------- ________% Legg Mason Part. Var. ________% Pioneer Small Cap Value VCT II DREYFUS FUNDS (Initial Shares) Large Cap Growth ________% Pioneer Strategic Income VCT II ------------------------------------------- ________% Legg Mason Part. Var. ________% Drey. IP Sm. Cap Stock Index Strategic Bond ________% Dreyfus VIF International Value -------------------------------------------- ________% Dreyfus Stock Index LORD ABBETT SERIES FUND, INC. ________% The Dreyfus Socially -------------------------------------------- Resp. Growth ________% Lord Abbett America's Value ________% Lord Abbett Growth and Income -------------------------------------------- NEUBERGER BERMAN ADVISERS MGMT TRUST JNL-6005-3 -------------------------------------------- Page 2 of 5 ________% NB AMT Fasciano
------------------------------------------- ------------------------------------------- ------------------------------------------- ROYCE CAPITAL FUND RYDEX VARIABLE TRUST (CONT.) TRANSACTION FEE FUNDS - NOTE: THERE IS AN ------------------------------------------- ------------------------------------------- ADDITIONAL FEE FOR INVESTING IN THE FUNDS ________% Royce Micro-Cap ________% Rydex Multi-Cap Core Equity LISTED BELOW. ________% Royce Micro-Cap ________% Rydex Nova -------------------------------------------- ------------------------------------------- ________% Rydex OTC -------------------------------------------- RYDEX VARIABLE TRUST ________% Rydex Precious Metals NATIONWIDE VARIABLE INSURANCE TRUST ------------------------------------------- ________% Rydex Real Estate ____---------------------------------------- ________% Rydex Absolute Return Strategies ________% Rydex Retailing _______% Nationwide VIT Bond Index ________% Rydex Banking ________% Rydex Russell(R) 2000 Advantage _______% Nationwide VIT International Index ________% Rydex Basic Materials ________% Rydex Sector Rotation _______% Nationwide VIT Mid Cap Index ________% Rydex Biotechnology ________% Rydex Small-Cap Growth _______% Nationwide VIT S&P 500 Index ________% Rydex Commodities ________% Rydex Small-Cap Value ___% Nationwide VIT Small Cap Index ________% Rydex Consumer Products ________% Rydex Technology ________% Rydex Dynamic Dow ________% Rydex Telecommunications ________% Rydex Dynamic OTC ________% Rydex Transportation ________% Rydex Dynamic Russell 2000 ________% Rydex U.S. Gov't Money Market ________% Rydex Dynamic S&P 500(R) ________% Rydex Utilities ________% Rydex Dynamic Strengthening ------------------------------------------- Dollar SELIGMAN PORTFOLIOS, INC. ________% Rydex Dynamic Weakening Dollar ------------------------------------------- ________% Rydex Electronics ________% Seligman Communications & ________% Rydex Energy Information ________% Rydex Energy Services ________% Seligman Global Technology ________% Rydex Essential Portfolio ------------------------------------------- Aggressive THIRD AVENUE VAR. SERIES TRUST ________% Rydex Essential Portfolio ------------------------------------------- Conservative ________% Third Avenue Value Portfolio ________% Rydex Essential Portfolio ------------------------------------------- Moderate T. ROWE PRICE EQUITY SERIES, INC. ________% Rydex Europe Advantage ------------------------------------------- ________% Rydex Financial Services ________% T. Rowe Price Blue Chip Growth ________% Rydex Gov't Long Bond ________% T. Rowe Price Equity Income Advantage ________% T. Rowe Price Health Sciences ________% Rydex Health Care ________% T. Rowe Price Limited-Term Bond ________% Rydex Hedged Equity ------------------------------------------- ________% Rydex Internet VAN ECK WORLDWIDE INSURANCE ________% Rydex Inverse Dynamic Dow ------------------------------------------- ________% Rydex Inverse Gov't Long Bond ________% Van Eck Worldwide Absolute Return ________% Rydex Inverse Mid-Cap ________% Van Eck Worldwide Bond ________% Rydex Inverse OTC ________% Van Eck Worldwide Emerging Markets. ________% Rydex Inverse Russell(R) 2000 ________% Van Eck Worldwide Hard Assets ________% Rydex Inverse S&P 500(R) ________% Van Eck Worldwide Real Estate ________% Rydex Japan Advantage ________% Rydex Large-Cap Growth ------------------------------------------- ________% Rydex Large-Cap Value WELLS FARGO ADVANTAGE FUNDS ________% Rydex Leisure ------------------------------------------- ________% Rydex Mid-Cap Advantage ________% Wells Fargo Advantage VT Discovery ________% Rydex Mid-Cap Growth ________% Wells Fargo Advantage VT Opportunity ________% Rydex Mid-Cap Value ==================================================================================================================================== 6. REBALANCING INSTRUCTIONS ------------------------------------------------------------------------------------------------------------------------------------ Rebalance contract: [_] Annually [_] Semi-Annually [_] Quarterly ------------------------------------------------------------------------------------------------------------------------------------ JNL-6005-3 Page 3 of 5
==================================================================================================================================== 7. ELECTRONIC ACCESS ------------------------------------------------------------------------------------------------------------------------------------ As 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. OWNER/ANNUITANT E-MAIL ADDRESS (REQUIRED)______________________ ==================================================================================================================================== 8. INVESTMENT ADVISOR AUTHORIZATION (TO BE SIGNED BY INVESTMENT ADVISOR, IF ANY.) ------------------------------------------------------------------------------------------------------------------------------------ Will the proposed contract replace any existing annuity IF YES, REPLACEMENT REQUIREMENTS MUST BE FOLLOWED. or insurance contract? [_] No [_] Yes (ALL TRANSFERS AND/OR EXCHANGES ARE CONSIDERED REPLACEMENTS.) I, the Investment Advisor, have reviewed the Contract Owner's financial status, tax status, and investment objectives and determined that the annuity for which the Contract Owner is applying is suitable. Enclose FORM VA-125 SUITABILITY FOR RIA-ADVISED SALES signed by the Contract Owner. ALSO ENCLOSE COPY OF EXECUTED ADVISOR AUTHORIZATION AGREEMENT FOR EACH ADVISOR ON THE CONTRACT. ------------------------------------------------------------------------------------------------------------------------------------ A. SIGNATURE OF INVESTMENT ADVISOR: B. NAME OF ADDITIONAL ADVISOR (THIRD PARTY INVESTMENT ADVISOR): -------------------------------------- -------------------------- ------------------------------------------------------------------ Print Name of Investment Advisor: Name of Firm: -------------------------------------- -------------------------- ------------------------------------------------------------------ Address: Address: -------------------------------------- -------------------------- -------------------------------------- --------------------------- Phone: Tax ID # / SS #: Phone: Tax ID # / SS #: -------------------------------------- -------------------------- -------------------------------------- --------------------------- E-Mail (REQUIRED): E-Mail (REQUIRED): ==================================================================================================================================== 9. REGISTERED REPRESENTATIVE CERTIFICATION (TO BE SIGNED BY REGISTERED REPRESENTATIVE, IF ANY.) ------------------------------------------------------------------------------------------------------------------------------------ I certify that I have asked all the questions in the application and correctly recorded the answers of the proposed Owner/Annuitant. I have presented to the Company all the pertinent facts, and I know nothing unfavorable about the proposed Owner/Annuitant that is not stated in this application. ----------------------------------------------------------------- ------------------------------------------------------------------ A. SIGNATURE OF REGISTERED REPRESENTATIVE #1: B. SIGNATURE OF REGISTERED REPRESENTATIVE #2: ----------------------------------------------------------------- ------------------------------------------------------------------ Print Name: Print Name: ----------------------------------------------------------------- ------------------------------------------------------------------ Date: Date: ----------------------------------------------------------------- ------------------------------------------------------------------ Address: Address: ----------------------------------------------------------------- ------------------------------------------------------------------ Phone #: Phone #: ----------------------------------------------------------------- ------------------------------------------------------------------ E-mail (REQUIRED): E-mail (REQUIRED): ----------------------------------------------------------------- ------------------------------------------------------------------ C. NAME OF SERVICING REPRESENTATIVE FOR THIS CONTRACT: ----------------------------------------------------------------- ------------------------------------------------------------------ Servicing Representative Phone #: ----------------------------------------------------------------- ------------------------------------------------------------------ Servicing Representative E-mail (REQUIRED): ----------------------------------------------------------------- ------------------------------------------------------------------ JNL-6005-3 Page 4 of 5
==================================================================================================================================== 10. FRAUD WARNINGS ------------------------------------------------------------------------------------------------------------------------------------ NAIC MODEL FRAUD STATMENT: Any person who knowingly NJ: An person who includes any false or misleading presents a false or fraudulent claim for payment of a loss information on an application for an insurance policy is or benefit or knowingly presents false information in an subject to criminal and civil penalties. 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 FL: An person who knowingly and with intent to injure, knowingly provide false, incomplete or misleading defraud, or deceive any insurer files a statement of information to an insurance company for the purpose of claim or an application containing any false, incomplete defrauding the company. Penalties may include or misleading information is guilty of a felony of the imprisonment, fines, or a denial of insurance benefits. third degree. ------------------------------------------------------------------------------------------------------------------------------------
==================================================================================================================================== 11. 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 registered representative assisted me in the purchase of this variable annuity, he/she is acting as an agent of Jefferson National.
---------------------------------------------------------------- NOT FDIC/NCUA INSURED | MAY LOSE VALUE | NO BANK GUARANTEE [GRAPHIC OMITTED] NOT A DEPOSIT | NOT INSURED BY ANY FEDERAL GOVERNMENT AGENCY [GRAPHIC OMITTED] ---------------------------------------------------------------- Will the proposed contract replace any existing annuity IF YES, REPLACEMENT REQUIREMENTS MUST BE FOLLOWED. or insurance contract? [_] No [_] Yes (ALL TRANSFERS AND/OR EXCHANGES ARE CONSIDERED REPLACEMENTS.) ----------------------------------------------------------------- ------------------------------------------------------------------ Signature of Owner: Signature of Joint Owner: ----------------------------------------------------------------- ------------------------------------------------------------------ Date: Date: ------------------------------------------------------------------------------------------------------------------------------------ FOR HOME OFFICE USE ------------------------------------------------------------------------------------------------------------------------------------ JNL-6005-3 Page 5 of 5