Exhibit 5

EX-5 2 dex5.htm EXHIBIT 5 Exhibit 5

EXHIBIT (5)

FORM OF APPLICATION


		VARIABLE ANNUITY APPLICATION
		Mail the application and a check to:		Transamerica Life Insurance Company
				Attn: Variable Annuity Dept.
		Service Office:		P.O. Box 3183, Cedar Rapids, IA 52406-3183
		Overnight Mailing Address:		4333 Edgewood Rd. NE, Cedar Rapids, IA 52499

1.	TYPE OF ANNUITY (SOURCE OF FUNDS)

Initial purchase payment $ ____________________________

¨	Non Qualified

New Money ¨ 1035 Exchange

Qualified

New Money ¨ Rollover ¨ Transfer

Qualified

Type:

¨ IRA ¨ Roth IRA ¨ SEP/IRA ¨ 403(b)

¨ Keogh ¨ Roth Conversion ¨ Other ___________

IRA/SEP/Roth IRA

$ ________________ Contribution for tax year ________

$ ________________ Trustee to Trustee Transfer

$ ________________ Rollover from

¨ IRA ¨ 403(b) ¨ Pension ¨ Other ___________

Roth

IRA Rollover

____________ Date first established or date of conversion

$____________ Portion previously taxed

2(a).

PRIMARY OWNER INFORMATION

If no Annuitant is specified in #3, the Owner will be the Annuitant. If a Trust is named as Owner or Beneficiary, additional paperwork will be required.

First Name: ________________________________________

Last Name: _________________________________________

Address: ___________________________________________

City, State: _________________________________________

Zip: ________-_________ Telephone: ___________________

Email Address (optional):_____________________________

Date of Birth: _____________ Sex: ¨ Female ¨ Male

SSN/TIN: __________________ Citizenship: ¨ U.S. ¨ Other

2(b).

JOINT OWNER INFORMATION (Optional)

First Name: ________________________________________

Last Name: ________________________________________

Address: ___________________________________________

City, State: _________________________________________

Zip: ________-_________ Telephone: ___________________

Date of Birth: _____________ Sex: ¨ Female ¨ Male

SSN/TIN: __________________ Citizenship: ¨ U.S. ¨ Other

3.	ANNUITANT

Complete only if different from Primary Owner.

First Name: ________________________________________

Last Name: ________________________________________

Address: ___________________________________________

City, State: _________________________________________

Zip: ________-_________ Telephone: ___________________

Date of Birth: _____________ Sex: ¨ Female ¨ Male

SSN: _______________________ Citizenship: ¨ U.S. ¨ Other

4.	BENEFICIARY(IES) DESIGNATION


Name	Relationship			¨ Primary
		____	%	¨ Contingent
Name	Relationship			¨ Primary
		____	%	¨ Contingent
Name	Relationship			¨ Primary
		____	%	¨ Contingent
Name	Relationship			¨ Primary
		____	%	¨ Contingent
Name	Relationship			¨ Primary
		____	%	¨ Contingent

5.	GUARANTEED DEATH BENEFITS

If no option is specified, the Policy Value Death Benefit will apply. Your selection cannot be changed after the policy has been issued.

¨	Policy Value Death Benefit, available for issue through age 90.

¨	Return of Premium Death Benefit, available for issue through age 90.

¨	Annual Step-Up Death Benefit, available for issue through age 75.

6.	OTHER AVAILABLE RIDERS

If no selection is made, the benefit will not apply.

You may choose one of the following benefits:


¨ Beneficiary Earnings Enhancement (BEE)		or		¨ Beneficiary Earnings Enhancement - EXTRA II (BEE-EXTRA II)

7.	TELEPHONE TRANSFER AUTHORIZATION

Please complete this section to authorize you and/or your Registered Representative to make transfer requests via our recorded telephone line or internet. (check one selection only):


¨ Owner(s) only,		or		¨ Owner(s) and Owner’s Registered Representative


VA-APP 01/04 (FQ) (CT)				81314097 02/05
				(1 of 3)

8.	PORTFOLIO INVESTMENT STRATEGY

¨	Lump Sum

I elect to allocate 100% of my contributions according to percentage listed in Section 10 “Lump Sum Allocation”.

¨	Dollar Cost Averaging (DCA) Program

I elect to allocate 100% of my contributions according to percentages listed in Section 11 “DCATransfer Allocation”.

¨	Combined: Lump Sum and DCA Program *(must total 100%)*

I elect to allocate as follows:

__________% as a lump-sum contributions according to percentages listed in Section 10 “Lump Sum Allocation”.

__________% in the DCA Account and transferred according percentages listed in Section 11 “DCA Transfer Allocation”.

9.	DCA TRANSFER STRATEGY

DCA Strategy (There is a $500 minimum transfer amount for the DCA program.)

Transfer from: (Select 1 of the following)

¨	1. Enhanced 6 Month DCA Fixed Account

¨	2. Enhanced 12 Month DCA Fixed Account

¨	3. DCA Fixed Account:

¨ 12 Mo. ¨ 18 Mo. ¨ 24 Mo. ¨ Other ________ _______

(Specify period and frequency)

Complete Section 11 for DCA transfer allocation.

¨ 4. Money Market Account:

¨ 12 Mo. ¨ 18 Mo. ¨ 24 Mo. ¨ Other _________ _________

(Specify

period and frequency)

¨ 5. Transamerica US Government Securities:

¨ 18 Mo. ¨ 24 Mo. ¨ Other _________ _________

(Specify period and frequency)

10.

LUMP SUM ALLOCATION

Fixed Accounts:

_______ .0% 1 Year Fixed Guarantee Period Option

_______ .0% 3 Year Fixed Guarantee Period Option

_______ .0% 5 Year Fixed Guarantee Period Option

Subaccounts:

_______ .0% AEGON Bond – Service Class

_______ .0% AIM V.I. Blue Chip Fund-Series II

_______ .0% AIM V.I. Core Equity Fund-Series II

_______ .0% AIM V.I. Government Securities Fund – Series II

_______ .0% AIM V.I. International Growth Fund – Series II

_______ .0% AllianceBernstein Premier Growth Portfolio-Class B

_______ .0% AllianceBernstein Technology Portfolio – Class B

_______ .0% Capital Guardian Global-Service Class

_______ .0% Capital Guardian Value – Service Class

_______ .0% Clarion Real Estate Securities – Service Class

_______ .0% Colonial Small Cap Value Fund, Variable Series – Class A

_______ .0% Davis Value Portfolio

_______ .0% Federated American Leaders Fund II

_______ .0% Federated Capital Income Fund II

_______ .0% Federated Growth & Income-Service Class

_______ .0% Federated High Income Bond Fund II

_______ .0% Federated Quality Bond Fund II

_______ .0% Fidelity-VIP Contrafund^{^®}Portfolio-Service Shares 2

_______ .0% Fidelity – VIP Equity Income Portfolio – Service Class 2

_______ .0% Fidelity-VIP Growth & Income Portfolio-Service Shares 2

_______ .0% Fidelity – VIP Growth Portfolio – Service Class 2

_______ .0% Fidelity-VIP Index 500 Portfolio-Service Shares 2

_______ .0% Fidelity-VIP High Income Portfolio-Service Shares 2

_______ .0% Fidelity – VIP Investment Grade Bond Portfolio – Service Class 2

_______ .0% Fidelity – VIP Mid Cap Portfolio – Service Class 2

_______ .0% Fidelity – VIP Overseas Portfolio – Service Class 2

_______ .0% Fidelity-VIP Value Strategies Portfolio-Service Shares 2

_______ .0% Franklin Growth and Income Securities Fund-Class 2

_______ .0% Franklin Small Cap Fund - Class 2

_______ .0% Huntington Growth Fund

_______ .0% Huntington VA Dividend Capture Fund

11.

DCA TRANSFER ALLOCATION

Transfer To: