EX-99.(5)(D) 5 dex995d.txt DEFERRED VARIABLE ANNUITY APPLICATION REVISED 1-06 Exhibit 5(d) ================================================================================================================================ The Travelers Insurance Company The Travelers Life and Annuity Company Deferred Variable Annuity Application One Cityplace . Hartford, CT 06103-3415 ================================================================================================================================ Owner Information -------------------------------------------------------------------------------------------------------------------------------- Name SS# -------------------------------------------------------------------------------------------------------------------------------- Street Address Sex [ ] Male Date of Birth [ ] Female -------------------------------------------------------------------------------------------------------------------------------- City, State, Zip U.S. Citizen [ ] Y [ ] N If no, please indicate country of citizenship ================================================================================================================================ Beneficiary Information If no boxes are checked, the default will be primary beneficiaries. Unless otherwise indicated, proceeds will be divided equally. Use special request section to provide additional beneficiaries or beneficiary information. Unless otherwise indicated, if any of the beneficiaries predecease the Owner and/or Annuitant, payment due to multiple beneficiaries shall be paid in equal shares to the surviving beneficiaries. -------------------------------------------------------------------------------------------------------------------------------- Full Name (First, M.I., Last) SSN/TIN Relationship to Owner % to Receive -------------------------------------------------------------------------------------------------------------------------------- Primary -------------------------------------------------------------------------------------------------------------------------------- [ ] Primary [ ] Contingent -------------------------------------------------------------------------------------------------------------------------------- [ ] Primary [ ] Contingent -------------------------------------------------------------------------------------------------------------------------------- [ ] Primary [ ] Contingent -------------------------------------------------------------------------------------------------------------------------------- [ ] Primary [ ] Contingent ================================================================================================================================ Maturity Date: ____/____/_____. ================================================================================================================================ Type of Plan (Please check only one) Initial Purchase Payment [ ] IRA Rollover [ ] Pension/Profit Sharing [ ] TSA ERISA [ ] 457 Def Comp Plan $__________________________ [ ] TSA [ ] Other_____________ Minimum Payment Requirement $20,000 ================================================================================================================================ Replacement Information Do you have any existing life insurance policies or annuity contracts? [ ] Yes [ ] No If yes, please provide details: Insurance Company Name: _____________________________ Contract Number: ______________________ Will the purchase of this annuity result in the replacement of any existing life insurance policy or annuity contract in this or any other company? [ ] Yes [ ] No If yes, provide information below: Insurance Company Name: _____________________________ Contract Number: ______________________ Use the Special Requests section to provide additional insurance companies and contract numbers. Attach any required state replacement and/or 1035 exchange/transfer forms. State replacement forms may be required in certain states even if a replacement is not involved. ================================================================================================================================ L-19066APP *L22213* Order # L-22213 1 of 4; Rev. 1-06
================================================================================================================================ NOTE: Effective July 1, 2004, applicants age 60 or older purchasing a contract in California must also submit form L-24021. ================================================================================================================================ ================================================================================================================================ Investment Options (total must equal 100%) -------------------------------------------------------------------------------------------------------------------------------- Name Code Pct Name Code Pct -------------------------------------------------------------------------------------------------------------------------------- AIM Capital Appreciation Portfolio KC % PIMCO VIT Real Return Portfolio - Adm Class PR % American Funds Global Growth Fund - Class 2 Shares IL % PIMCO VIT Total Return Portfolio PM % American Funds Growth Fund - Class 2 Shares IG % Pioneer Fund Portfolio UP % American Funds Growth-Income Fund - Class 2 Shares II % Pioneer Mid Cap Value Portfolio FW % Capital Appreciation Fund (Janus) US % Pioneer Strategic Income Portfolio HP % Citistreet Diversified Bond Fund - Class I OB % Putnam VT Small Cap Value Fund - Class IB Shares OP % Citistreet International Stock Fund - Class I OI % Salomon Brothers Variable All Cap Fund - Class I AD % Citistreet Large Company Stock Fund - Class I OC % Salomon Brothers Variable Investors Fund - C2 % Class I Citistreet Small Company Stock Fund - Class I OE % SB Adjustable Rate Income Portfolio BI % Delaware VIP REIT Series AQ % Smith Barney Aggressive Growth Portfolio SG % Delaware VIP Small Cap Value Series AP % Smith Barney Appreciation Portfolio 1N % Dreyfus VIF Appreciation Portfolio DP % Smith Barney High Income Portfolio HH % Dreyfus VIF Developing Leaders Portfolio DS % Smith Barney Large Cap Growth Portfolio AB % Equity Income Portfolio (Fidelity) 4F % Smith Barney Small Cap Growth Opportunities C9 % Portfolio Equity Index Portfolio - Class II GF % Social Awareness Stock Portfolio (Smith Barney) SA % Fidelity VIP Contrafund(R)Portfolio-Service Class 2 FT % Strategic Equity Portfolio (Fidelity) HA % Fidelity VIP Mid Cap Portfolio - Service Class 2 D1 % Style Focus Series: Small Cap Growth Portfolio FY % Franklin Mutual Shares Securities Fund - Class 2 R2 % Style Focus Series: Small Cap Value Portfolio F0 % Janus Aspen Series Mid Cap Growth Portfolio - JA % Templeton Developing Markets Securities Fund - VQ % Service Shares Class 2 Large Cap Portfolio (Fidelity) 4G % Templeton Foreign Securities Fund - Class 2 VG % Lazard Retirement Small Cap Portfolio RS % Templeton Growth Securities Fund - Class 2 Q2 % Lord Abbett Series Growth and Income Portfolio FK % Travelers Convertible Securities Portfolio AF % Lord Abbett Series Mid-Cap Value Portfolio FL % Travelers Disciplined Mid Cap Stock Portfolio 1M % Mercury Large Cap Core Portfolio DR % Travelers High Yield Bond Trust UB % MetLife Aggressive Allocation Portfolio H9 % Travelers Managed Assets Trust UA % MetLife Conservative Allocation Portfolio H5 % Travelers Money Market Portfolio 1K % MetLife Conservative to Moderate Allocation Portfolio H6 % Travelers Quality Bond Portfolio 4W % MetLife Moderate Allocation Portfolio H7 % Travelers U.S. Government Securities Portfolio GV % MetLife Moderate to Aggressive Allocation Portfolio H8 % Van Kampen LIT Comstock Portfolio - Class II NJ % Shares MFS Mid Cap Growth Portfolio DQ % Fixed Account (where approved) % MFS Total Return Portfolio HT % % MFS Value Portfolio BD % % Mondrian International Stock Portfolio 4C % % -------------------------------------------------------------------------------------------------------------------------------- Oppenheimer Main Street Fund/VA - Service Shares H2 % TOTAL 100% ================================================================================================================================ ================================================================================================================================ Death Benefit Selection (Beneficiary Protection) Please select one of the following options for the variable annuity product you are purchasing. If no option is checked, you will receive the Standard Death Benefit. -------------------------------------------------------------------------------------------------------------------------------- [ ] Standard Death Benefit [ ] Optional Death Benefit and Credit Endorsement ================================================================================================================================ Special Programs This option is available at NO additional cost. If checked, please attach appropriate form. [ ] Dollar Cost Averaging ================================================================================================================================ Special Requests ================================================================================================================================ L-19066APP *L22213* Order # L-22213 2 of 4; Rev. 1-06
================================================================================================================================ Disclosure & Acknowledgment -------------------------------------------------------------------------------------------------------------------------------- NOTICES OF INSURANCE FRAUD: The following states require insurance applicants to be given a fraud warning statement. Please read the appropriate fraud warning statement for the state you reside in as indicated below. Arkansas, Louisiana, New Mexico: 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 civil fines and criminal penalties. Colorado: It is unlawful to knowingly provide false, incomplete, or 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 life insurance, and civil damages. It is also unlawful for 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 respect to a settlement or award payable from insurance proceeds. Such acts shall be reported to the Colorado Division of Insurance with the Department of Regulatory Agencies to the extent required by applicable law. District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Florida: A person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim containing false, incomplete or misleading information is guilty of a felony of the third degree. Kentucky: Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Maine, Tennessee: 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. New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Ohio: A person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing false or deceptive statement is guilty of insurance fraud. Oklahoma: WARNING: Any person who knowingly, and with the intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete, or misleading information is guilty of a felony. Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Puerto Rico: Any person who, knowingly and with the intention to defraud, includes false information in an application for insurance or files, assists, or abets in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same damage or loss, commits a felony, and if found guilty shall be punished for each violation with a fine no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years. -------------------------------------------------------------------------------------------------------------------------------- I/we understand the contract will take effect when the first purchase payment is received and the application is approved in the Home Office of the Company. I understand that annuity payments and termination values provided by this contract are variable and are not guaranteed as to a fixed dollar amount. No representative is authorized to make changes to the contract or application. I ACKNOWLEDGE RECEIPT OF A CURRENT PROSPECTUS. ================================================================================================================================ Owner's Signature City, State Where Signed (REQUIRED) Date ================================================================================================================================ L-19066APP *L22213* Order # L-22213 3 of 4; Rev. 1-06
================================================================================================================================ Representative Use Only -------------------------------------------------------------------------------------------------------------------------------- I acknowledge that all data representations and signatures were recorded by me or in my presence in response to my inquiry and request and that all such representations and signatures are accurate and valid to the best of my knowledge and belief. Will the contract applied for replace any existing annuity or life insurance policy? [ ] Yes [ ] No -------------------------------------------------------------------------------------------------------------------------------- Representative's Name (Please print) Date -------------------------------------------------------------------------------------------------------------------------------- Representative's Signature SS# -------------------------------------------------------------------------------------------------------------------------------- Phone # Fax # License # (Florida Only) -------------------------------------------------------------------------------------------------------------------------------- Broker/Dealer -------------------------------------------------------------------------------------------------------------------------------- For Citistreet Use Only (Circle one) Select One: [ ] A [ ] B [ ] C C / E / G / H ================================================================================================================================ L-19066APP *L22213* Order # L-22213 4 of 4; Rev. 1-06