EX-99.(5)(K) 12 dex995k.txt TIC GROUP DEFERRED VARIABLE ANNUITY APPLICATION (NEW YORK) L-22535NY 1-06 Exhibit 5(k) ================================================================================================================================ The Travelers Insurance Company Group Deferred Variable Annuity Application One Cityplace . Hartford, CT 06103-3415 (New York) ================================================================================================================================ Certificate Owner/Annuitant 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 -------------------------------------------------------------------------------------------------------------------------------- Full Name (First, M.I., Last) SSN/TIN Relationship to Owner % to Receive -------------------------------------------------------------------------------------------------------------------------------- Primary -------------------------------------------------------------------------------------------------------------------------------- [ ] Primary [ ] Contingent -------------------------------------------------------------------------------------------------------------------------------- [ ] Primary [ ] Contingent -------------------------------------------------------------------------------------------------------------------------------- [ ] Primary [ ] Contingent -------------------------------------------------------------------------------------------------------------------------------- [ ] Primary [ ] Contingent ================================================================================================================================ Maturity Date: ____/____/_____ (Will be set to age 90 unless otherwise specified) ================================================================================================================================ Type of Plan (Please check only one) [ ] IRA Rollover [ ] Pension/Profit Sharing [ ] TSA ERISA [ ] 457 Def Comp Plan [ ] TSA [ ] Other_____________ ================================================================================================================================ 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 the 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-22535NY *L22535NY* Order # L-22535NY 1 of 3; Rev. 1-06
================================================================================================================================ Allocation Schedule (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 OP % Shares 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% -------------------------------------------------------------------------------------------------------------------------------- ================================================================================================================================ Please check the following if choosing the Optional Death Benefit and Credit Endorsement: -------------------------------------------------------------------------------------------------------------------------------- [ ] Yes, I elect the Optional Death Benefit and Credit Endorsement (if not, you will receive the Standard Death Benefit) ================================================================================================================================ Dollar Cost Averaging/Systematic Withdrawal Programs (If checked, please attach completed form) -------------------------------------------------------------------------------------------------------------------------------- Dollar Cost Averaging [ ] Y [ ] N Systematic Withdrawal [ ] Y [ ] N ================================================================================================================================ Special Requests ================================================================================================================================ PLEASE READ AND SIGN PAGE 3 ================================================================================================================================ L-22535NY *L22535NY* Order # L-22535NY 2 of 3; Rev. 1-06
================================================================================================================================ Disclosures and Acknowledgment -------------------------------------------------------------------------------------------------------------------------------- I/We understand the certificate will take effect when the first premium is received, and the data collection form is approved in the Home Office of the Company. All payments and values provided by the certificate applied for, when based on investment experience of a separate account, are variable and are not guaranteed as to a fixed dollar amount. No agent is authorized to make changes to the certificate or data collection form. I understand that the Company may amend this certificate to comply with changes in the Internal Revenue Code and related regulations. [ ] I ACKNOWLEDGE RECEIPT OF A CURRENT PROSPECTUS. -------------------------------------------------------------------------------------------------------------------------------- Certificate Owner's Signature City, State Where Signed (REQUIRED) Date -------------------------------------------------------------------------------------------------------------------------------- ================================================================================================================================ Representative Use Only -------------------------------------------------------------------------------------------------------------------------------- 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 criminal and civil penalties, including imprisonment, fines and denial of insurance benefits. 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 # -------------------------------------------------------------------------------------------------------------------------------- Broker/Dealer -------------------------------------------------------------------------------------------------------------------------------- For Citistreet Use Only (Circle one) Select One: [ ] A [ ] B [ ] C C / E / G / H ================================================================================================================================ L-22535NY *L22535NY* Order # L-22535NY 3 of 3; Rev. 1-06