Exhibit 5

STATE FARM LlFE AND ACCIDENT ASSURANCE COMPANY Bloomington, Illinois

PAGE 1 OF 6 Doc Type: 01 Check Digit

VARIABLE UNIVERSAL LlFE INSURANCE APPLICATION

1. TYPE OF APPLICATION (check one)

New Business

Change of Plan/Added Benefits Existing Policy Number:

Variable Universal Life Increase Existing Policy Number:

Term Conversion with Increase in Amount Existing Policy Number:

2. PROPOSED INSURED 1

(Print name in full)

MR

MS

LAST NAME FIRST NAME MIDDLE INITIAL a.

MAILING ADDRESS CITY STATE ZIP CODE IN CITY? YES NO

b.

SOCIAL SECURITY OR TAX IDENTIFICATION NUMBER DRIVER’S LICENSE NUMBER STATE SEX BIRTH DATE MO-DAY-YR AGE

c.

MARITAL STATUS

HEIGHT WEIGHT STATE OF BIRTH

UNITED STATES OR CANADIAN CITIZEN?

YES NO

d.

OCCUPATION

EMPLOYER’S NAME e.

Do job duties involve work in one of the following occupation categories: amusement, sports, construction, explosives, diving, liquor, logging, mining, gas, or oil? (If yes, explain exact duties)

YES NO f.

3. PROPOSED INSURED 2 (Additional Insured or Payor, print name in full)

MR MS

LAST NAME FIRST NAME MIDDLE INITIAL a.

SOCIAL SECURITY OR TAX IDENTIFICATION NUMBER DRIVER’S LICENSE NUMBER STATE SEX BIRTH DATE MO-DAY-YR AGE b.

MARITAL STATUS HEIGHT WEIGHT STATE OF BIRTH

UNITED STATES OR CANADIAN CITIZEN?

YES NO

c. OCCUPATION EMPLOYER’S NAME d.

Do job duties involve work in one of the following occupation categories: amusement, sports, construction, explosives, diving, liquor, logging, mining, gas, or oil? (If yes, explain exact duties)

YES NO e.

4. APPLICANT/OWNER (If not Proposed Insured 1, print name in full)

LAST NAME FIRST NAME MIDDLE INITIAL SOCIAL SECURITY OR TAX IDENTIFICATION NUMBER a.

MAILING ADDRESS

CITY

STATE ZIP CODE

IN CITY? YES NO

b.

Successor Owner (Required unless the Applicant/Owner is a TRUST or CORPORATION)

LAST NAME FIRST NAME

MIDDLE INITIAL c.

5. Complete 5 if Proposed Insured is under age 16 a. Is Proposed Insured to be Owner at and after age 21? þ

YES NO b. Give amount of insurance in force on: (If none, so indicate)

Father $ Mother $

121590 (NY) 06-07-2005

PAGE 2 OF 6

6. VARIABLE UNIVERSAL LIFE

a. Initial Basic Amount: $

b. Death Benefit: (Complete for new policy only)

If no option is chosen, policy provisions determine the option.

Option 1 — Basic Amount Option 2 — Basic Amount plus Account Value c. Riders/Benefits applied for: (Check Ratebook for availability of riders.)

YES NO

Waiver of Monthly Deduction (PI 1 only)

Guaranteed Insurability Option $ Level Term (PI 2) $

Children’s Term Rider Units d. Dividend Option:

If no option is chosen, policy provisions determine option.

Increase in Basic Amount

Cash e. Planned Premium:

Mode chosen:

Annual

SFPP Existing SFPP Account #:

Other Special Monthly:

Amount to be billed each payment date: $ f. Increase in Basic Amount: (Do not complete for new policy.) $

g. Initial Account and Payment Allocation: (Complete for new policy only.)

All net premiums are allocated to the Fixed Account for 20 days from the issue date of the policy. Percentages must be whole numbers.

Small Cap Equity Subaccount Small Cap Equity Index Subaccount International Equity Subaccount International Equity Index Subaccount Large Cap Equity Subaccount Large Cap Equity Index Subaccount Stock and Bond Balanced Subaccount Bond Subaccount Money Market Subaccount Fixed Account

TOTAL =

%

%%

%

%%

%%

% %

100%

YES NO h. Do you want to enroll in one of the following programs? (If Yes, indicate program and complete the appropriate request form.)

Dollar Cost Averaging (DCA) -or- Portfolio Rebalancing (PR) (Only one can be in effect at a time.) i. Premium submitted with the application: $

121590 (NY) 06-07-2005

PAGE 3 OF 6

7. BENEFICIARY DESIGNATION — Proposed Insured 1

Completion of this section will replace all previous rider and policy designations for this policy. If a Change of Plan or an addition in coverage, this designation will replace previous designations for this insured.

PRIMARY BENEFICIARY - FULL NAME RELATIONSHIP

SUCCESSOR BENEFICIARY - FULL NAME RELATIONSHIP

8. BENEFICIARY DESIGNATION — Proposed Insured 2

Complete for Additional Insured’s rider only if the Beneficiary provision in the rider is NOT desired. If this section is completed, the Payment of Benefit Provisions of the policy will control rather than the Beneficiary provision of such rider. “Additional Insured” would be used in place of the “Insured.” If a Change of Plan or an addition in coverage, this designation will replace previous designations for this insured.

PRIMARY BENEFICIARY - FULL NAME RELATIONSHIP

SUCCESSOR BENEFICIARY - FULL NAME RELATIONSHIP

Complete 9 if CTR applied for. List children under age 18 (if none, so state)

9. LAST NAME, FIRST NAME, MI (If last name different, explain) RELATIONSHIP TO PROPOSED INSURED 1 BIRTHDATE MO. DAY YR. AMOUNT NOW INSURED FOR $

Complete 10-12 if CTR applied for OR Proposed Insured 1 is under age 16.

10. In the last 10 years, has Proposed Insured 1 or any children named in question 9, had or been treated by a member of the medical profession for: (If yes, check all that apply and explain)

YES NO a. birth defect e. mental disorder i. impairment of sight, hearing, or speech b. asthma f. seizure j. diabetes c. kidney disease g. heart murmur k. anemia d. leukemia h. cancer

11. In the last 10 years, has Proposed Insured 1 or any children named in question 9, been diagnosed as having or been treated by a member of the medical profession for Acquired Immune Deficiency Syndrome (AIDS)?

12. In the last 3 years, has Proposed Insured 1 or any children named in question 9, seen a doctor for any reason not previously explained excluding any routine physical examination with normal findings? (If yes, explain)

121590 (NY) 06-07-2005

PAGE 4 OF 6

13. Complete for all Applications a. Is the total amount of insurance in force on you more than $200,000? (If yes, give amounts and details.) b. Is anyone now applying for life or health insurance on you with any other company?

(If yes, in Explanations state company and amounts.)

PI 1 PI 2

YES NO YES NO

Applications (Ages 16 & up): Complete 14-18

14. Have you used tobacco or other nicotine products in any form in the last 36 months?

(If yes, please provide month/year last used PI 1 / PI 2 / )

Month Year Month Year

15. In the last 10 years, have you had or been treated by a member of the medical profession for: (If yes, explain)

(Check all that apply) (Check all that apply)

P I 1 P I 2 PI 1 PI 2

a. cancer or tumor c. heart disease or disorder, chest pain, high blood pressure b. diabetes d. stroke or transient ischemic attack (TIA)

16. In the last 10 years, have you been diagnosed as having or been treated by a member of the medical profession for Acquired Immune Deficiency Syndrome (AIDS)?

17. In the last 3 years, have you: (If yes, explain) a. been convicted of or pleaded guilty to any moving violations or driving under the influence of alcohol or drugs? b. engaged in any type of aviation activity (other than as a passenger); or is any such activity planned in the next 6 months? c. engaged in avocations such as mountain/rock climbing, vehicle racing, SCUBA/skin diving, sky diving, ballooning or hang gliding, or is any such activity planned in the next 6 months?

18. Do you plan to leave or travel from the United States or Canada in the next 6 months? (If yes, explain)

Applications (Ages 16 & up if NO medical exam required): Complete 19-22

19. Have you ever applied for or received disability benefits; had an injury to your neck, back, arm, or leg; or had any loss of sight or hearing? (If yes, explain) PI 1 PI 2 YES NO YES NO

20. In the last 10 years, have you had or been treated by a member of the medical profession for: (If yes, explain)

(Check all that apply) (Check all that apply)

PI 1 PI 2 P I 1 P I 2

a. respiratory disorder c. mental or nervous disorder b. liver or intestinal disorder d. blood disorder

21. In the last 5 years, have you used cocaine, marijuana, or any other controlled substance or narcotic not prescribed by an authorized member of the medical profession; had treatment or counseling for alcohol or drug use, or been advised to seek treatment or counsel for alcohol or drug use? (lf yes, explain)

22. In the last 5 years, have you for any reason not previously explained: (If yes explain) a. seen a doctor or psychologist? b. had medication prescribed other than medications for cold, flu, seasonal allergies

(i.e. hay fever) or birth control? (If yes, list and explain) c. had or been advised to have treatment or a test (except for HIV) in any lab, clinic, or hospital? d. been told surgery was necessary?

121590 (NY) 06-07-2005

PAGE 5 OF 6

23. EXPLANATIONS:

If space below is insufficient, use additional sheets which will be part of this application. Sheets must be signed & dated by Proposed Insured(s), and/or Applicant, and witnessed by Agent.

121590 (NY) 06-07-2005

PAGE 6 OF 6

24. AGREEMENTS

Coverage will be effective as of the policy date if the following conditions are met: the first premium is paid when the policy is delivered; the Proposed Insureds are living on the delivery date; and, on that delivery date, the information given to the Company is true and complete without material changes to the best of their knowledge and belief.

For changes in Basic Amount, the change will be effective on the deduction date on or next following acceptance of the change by the Company if on such deduction date the following conditions are met: there is enough cash surrender value to make the required deduction; the Proposed Insureds are all living; and the information given to the Company is true and complete without material changes to the best of their knowledge and belief.

However, if a binding receipt has been given and is in effect, its terms apply.

All Proposed Insureds and the Applicant state that the information in this application and any medical history is true and complete to the best of their knowledge and belief. It is agreed that the Company can investigate the truth and completeness of such information while the policy is contestable.

By accepting the policy, the Owner agrees to the beneficiaries named and method of payment. No change will be made except for administrative purposes and only in a manner so as not to attribute the change to the Owner. Neither the agent nor a medical examiner may pass on insurability.

Any policy issued on this application will be owned by Proposed Insured 1 or the Applicant, if other than Proposed Insured 1. This application will be attached to and made part of the policy.

Proposed Insured 1 or the Applicant, if other than Proposed Insured 1:

Understands that the amount and duration of the death benefit may vary, depending on the investment performance of the variable accounts in the separate account; Understands that the policy values may increase or decrease, depending on the investment experience of the separate account; Understands the cash surrender value is paid on the maturity date and the amount of the cash surrender value is not guaranteed; Has been provided with the separate account prospectus and the fund prospectus for the policy applied for; and Understands that an illustration of benefits, including death benefits, policy values, and cash surrender values are available upon request.

SOCIAL SECURITY OR TAX IDENTIFICATION NUMBER (TIN) CERTIFICATION

By signing this application, I certify under penalties of perjury that (1) the TIN shown above is correct, and (2) I am exempt from backup withholding, or that I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding, (If you are subject to backup withholding, cross out item 2.) and (3) I am a U.S. person (Including a U.S. resident alien). The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. (See instructions.)

Date Signed Signature of Proposed Insured I X

Not required if Proposed Insured is under age 16

at Signature of Proposed Insured 2 X

City State

Signature of Agent as Signature of Witness to all Signatures X Applicant X

Not required unless applicant is other than Proposed Insured 1. If a firm or corporation is to be the owner, give its name and signature of authorized officer.

121590 (NY) 06-07-2005