Exhibit 99.(b)(5)

Capital Freedom Individual Deferred Variable Annuity Application If more space is needed, attach Supplemental Information ICC13-20140(1113) Section 1 - Owner M F Gender Y N U.S. Citizen M F Gender Y N U.S. Citizen Section 2 - Annuitant/Participant (if different than Owner) M F Gender Y N U.S. Citizen Section 3 - Beneficiary (For Joint Owners, If an Owner dies the surviving Owner is the sole beneficiary. For qualified policies see the plan documents.) IRA Roth IRA SIMPLE IRA SEP Non-Qualified Other (specify) Section 4 - Plan Qualification 403(b) Roth 403(b) 457(b) Roth 457(b) 401(k) Roth 401(k) Other (specify) 4a. 4b. Section 5 - Purchase Payment 5a. Initial Purchase Payment: (Approx) 5b. Salary Reduction/Deduction or PAC (Section 5c is required for PAC) Frequency?: Bi-Weekly Monthly Quarterly Semi-Annually Other Salary Reduction Only: Please indicate any skip months below if any are scheduled within the next 12 months: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 5c. Bank Information Checking Savings ICC14-20227(0114) National Life Group® is a trade name of National Life Insurance Company, Montpelier, VT and its affiliates. Page 1 of 4 Cat. No. 101987 P: 800-732-8939 ¦ F: 214-638-9162 ¦ Imaging@NationalLifeGroup.com ¦www.NationalLifeGroup.com One National Life Drive, Montpelier, VT 05604-5555 SSN/TIN DOB (mm/dd/yyyy) Country of Citizenship U.S. Citizen Owner's Name (First, Middle, Last) or Employer/Plan Name Phone Number Gender E-Mail Address Home Address (Street - No PO Boxes, City, State, Zip) Phone Number Joint Owner's Name (First, Middle, Last) (If applicable, for NQ only) Gender SSN/TIN Alien Registration # Country of Citizenship Relation to Owner DOB (mm/dd/yyyy) U.S. Citizen Alien Registration # E-Mail Address Phone Number Alien Registration # Country of Citizenship DOB (mm/dd/yyyy) SSN/TIN Annuitant's Name (First, Middle, Last) Country of Citizenship DOB (mm/dd/yyyy) SSN/TIN Annuitant's Name (First, Middle, Last) Relation to Owner Relation to Owner M F E-Mail Address Home Address (Street - No PO Boxes, City, State, Zip) Primary Beneficiary's Name (First, Middle, Last) Relation to Owner SSN/TIN Share (%) DOB (mm/dd/yyyy) Contingent Beneficiary's Name (First, Middle, Last) Relation to Owner SSN/TIN Share (%) DOB (mm/dd/yyyy) Contingent Beneficiary's Name (First, Middle, Last) Relation to Owner SSN/TIN Share (%) DOB (mm/dd/yyyy) Primary Beneficiary's Name (First, Middle, Last) Relation to Owner SSN/TIN Share (%) DOB (mm/dd/yyyy) Employer/District: School/Campus Name: Check $ Periodic Purchase Payment Amount: $ Start Date Bank Information5c. Bank Name CheckingSavings Bank Acct. # Routing #

Section 6 - Capital Freedom Rider (may not be available in all states) Rider charges, investment restrictions, and other limitations will apply if you select the Capital Freedom Rider. See the prospectus for full details. Do you select the Capital Freedom Rider? Yes No If the Annuitant is 55 or older, the Capital Freedom Rider will activate automatically. If the Annuitant is younger than 55, the Capital Freedom Rider will activate when the Annuitant is age 55, unless you choose to activate the rider earlier. You may activate the rider once the Annuitant is at least age 50. To activate the rider early, choose one of the following: 50 51 52 53 54 Section 7 - Document Delivery With respect to the required delivery of prospectuses and periodic fund reports, choose one of the following. I wish to receive these documents in paper format I wish to receive these documents over the internet by registering for the E-documents electronic delivery program. (Documents will be delivered in paper format until you have completed the online registration.) Section 8 - Telephone Transaction Agreement Unless waived below, I appoint the Company as my agent to act upon telephoned instructions reasonably believed to be authorized by me. I hereby ratify any telephoned instructions so given and consent to the tape recording of these instructions. So long as the Company employs reasonable procedures to confirm that the instructions are genuine, I agree that I will not hold the Company liable for any unauthorized telephoned instructions. This will allow me and my representative named below to transfer funds among subaccounts, change the fund allocation percentages, and add, cancel or change the Portfolio Rebalancing or Dollar Cost Averaging features. I do not authorize the Company to accept telephone instructions Section 9 - Replacement Yes No Do you have an existing life insurance or annuity policy with us or any other company? (If answered "Yes" in a NAIC state, a completed and signed NAIC Form A (8027) is required.) Yes No Will the proposed contract replace or change any existing annuity contract or life insurance policy? (If answered "Yes", list the insurance company name(s) and policy or contract number(s) below. A state specific replacement form may also be required.) Regardless of the answers to the above questions, please refer to “2630-Required States Forms” to determine the additional form(s) that may be required. Section 10 - For Home Office Endorsement Only ICC14-20227(0114) Page 2 of 4 Activate immediately (this option is available only if the Annuitant is 50 or older) Activate when the Annuitant is age: Representative(s)

Section 11 - Purchase Payment Allocation (must use whole percentages that combine to total 100%) Target Volatility Subaccounts (must total to at least 50% with the Capital Freedom Rider, see Section 6) DWS Risk Pilot VIP DWS Risk Pilot Domestic VIP Investment Subaccounts (total may not exceed 50% with the Capital Freedom Rider, see Section 6) Equity - Large Cap Value Fixed Income - High Quality, Short Franklin Templeton VIP Founding Funds Allocation DWS Money Market VIP Franklin Mutual Global Discovery Goldman Sachs VIT High Quality Income MFS Value Blackrock High Yield DWS Small Mid Cap Value VIP Pimco Low Duration Equity - Large Cap Blend Fixed Income - Low Quality, Short DWS Equity Index VIP Blackrock Value Opportunities T. Rowe Price Personal Strategy Balanced American Funds New World Pimco Emerging Markets Admin Equity - Small Cap Growth American Funds Global Small Cap Frequency: Time Period: 6 months 12 months ICC14-20227(0114) Page 3 of 4 Blackrock Money Market Franklin Income Securities Goldman Sachs VIT Money Market Blackrock Equity Dividend Pimco Short Term Admin MFS Mid Cap Value Templeton Global Bond Goldman Sachs VIT Structured Small Cap Equity MFS New Discovery Sentinel VP Small Company You may choose Portfolio Rebalancing and/or Dollar Cost Averaging. With the Capital Freedom Rider (see Section 6), Portfolio Rebalancing and Dollar Cost Averaging apply only to the Investment Account allocations. Portfolio Rebalancing Annual Semi-Annual Quarterly Dollar Cost Averaging (monthly transfers) MFS Utilities Fixed Income - Medium Quality, Short Equity - Medium Cap Value Goldman Sachs VIT Core Fixed Income American Funds Global Growth & Income Blackrock US Govt Bond Sentinel VP Common Stock DWS Gov & Agency Securities Fixed Income - Medium Quality, Intermediate Equity - Medium Cap Blend MFS Research Bond Equity - Small Cap Blend American Funds Global Bond Goldman Sachs VIT Growth Opportunities American Funds High-Income Bond Blackrock S&P 500 Index Goldman Sachs Equity Index Fixed Income - High Quality, Intermediate Franklin Rising Dividends Sentinel VP Bond Pimco Total Return Bond DWS Small Cap Index Fixed Income - Low Quality, Intermediate Equity - Large Cap Growth Pimco Long Term US Govt Admin MFS Global Equity Sentinel VP Balanced MFS Core Equity Pimco Global Bond (unhedged) Equity - Medium Cap Growth Fixed Income - Low Quality, Long Goldman Sachs VIT Mid Cap T. Rowe Price Blue Chip Growth Portfolio II DWS Unconstrained Income VIP Templeton Developing Markets Fixed Income - High Quality, Long American Funds Asset Allocation Fixed Income - Medium Quality, Long T. Rowe Price Health Sciences Portfolio II Franklin Strategic Income Blackrock Global Allocation Franklin High Income T. Rowe Price New America Growth Equity - Targeted Volatility DWS Risk Pilot VIP DWS Risk Pilot Domestic VIP If selected, Dollar Cost Averaging applies to all future Purchase Payments until you instruct us otherwise. MFS Mid Cap Value DWS Small Cap Index Sentinel VP Bond Pimco Total Return Bond

Section 12 - Notices/Acknowledgments Notice: Any person who knowingly presents a false statement in an application for insurance may be guilty of criminal offense and subject to penalties under state law. Acknowledgments: The Annuitant and the Owner, if other than the Annuitant; (1) represents, to the best of their knowledge and belief, that all statements and answers contained herein are full, complete and true as written and are correctly recorded; and, (2) expressly agrees as follows: 1. This application and the answers and agreements contained herein shall be the basis of, a part of the consideration for, and a part of the annuity hereby applied for. 2. The purchase payment is consideration to the Company for the granting of an annuity and upon payment becomes the property of the Company. 3. I authorize my employer, if applicable, to withhold the purchase payments to purchase the annuity for which I have applied. I authorize the Company to accept purchase payments on my behalf. 4. If applicable, I hereby request and authorize the Company to draw upon the Financial Institution listed in Section 5c provided there are sufficient funds in said account. This authorization shall remain in effect until revoked in writing by me, and received by the Company. I agree that the Company shall be fully protected in honoring the information in Section 5c and that if the information is rejected by said Financial Institution, whether with or without cause and whether intentionally or inadvertently, the Company will be under no liability whatsoever even though such rejection results in forfeiture of insurance coverage. 5. The annuity will not be effective until purchase payment is received by the Company or its designated Administrator and all the application requirements are received and deemed in good order. 6. The Company is authorized to amend this application by appropriate notation in Section 10 “For Home Office Endorsement Only” to correct errors or omissions. The acceptance of any annuity issued from this application is acceptance and ratification of the beneficiary designation, if any, in such annuity and of any amendments contemplated above except that no change shall be made in the plan of annuity or benefits without the written acceptance of the Owner. 7. If applicable, the undersigned Annuitant hereby adopts, subscribes and agrees to the terms of his/her Employer’s plan, as now in effect or hereafter modified, and further agrees to be bound by all actions taken by the representatives thereof pursuant to and in accordance with said plan. I have received a copy of all sales material including electronically presented material and understand that the results shown, other than the guaranteed minimum values, are not guarantees, promises or warranties. I have received a copy of the Privacy Notice. I understand that the contract values that are based upon the investment experience of a separate account are variable, are not guaranteed as to a fixed dollar amount and, will decrease or increase with investment experience. I acknowledge receipt of the Capital Freedom Variable Annuity Prospectus. Section 13 - Agent Section I certify that only sales material approved by the Company was used and that originals or copies of all sales material used were left with the applicant. I have not made statements that differ from this material nor have I made any promises about the expected future values of this policy. Is a replacement involved in this transaction? Yes No Section 14 - Commission (Please Note: If an Option is not selected, standard commissions will apply.) Option A (standard) Option B Option C Other (specify) ICC14-20227(0114) Page 4 of 4