Exhibit

EX-99.5 4 ex995tdwususl.htm EXHIBIT 99.5 Exhibit

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INDIVIDUAL MARKET VALUE ADJUSTED VARIABLE ANNUITY APPLICATION

[company name]LIFE INSURANCE COMPANY

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1. OWNER

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Name

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Last First Middle

Address

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Street

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City State Zip

Phone ( )

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SOC. SEC. # / / / / / / / / / / / /

DATE OF BIRTH / / / / / / / / /

(Month Day Year)

Sex: / / Male / / Female

/ / Citizen of U.S.

/ / Resident Alien of U.S.

/ / Other

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2. CO-OWNER (optional)

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Name

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Last First Middle

Address

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Street

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City State Zip

Phone ( )

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SOC. SEC. # / / / / / / / / / / / /

DATE OF BIRTH / / / / / / / / /

(Month Day Year)

Sex: / / Male / / Female

/ / Citizen of U.S.

/ / Resident Alien of U.S.

/ / Other

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3. ANNUITANT (If other than owner)

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Name

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Last First Middle

Address

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Street

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City State Zip

Phone ( )

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SOC. SEC. # / / / / / / / / / / / /

DATE OF BIRTH / / / / / / / / /

(Month Day Year)

Sex: / / Male / / Female

/ / Citizen of U.S.

/ / Resident Alien of U.S.

/ / Other

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4. ADDITIONAL ANNUITANT (optional)

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Name

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Last First Middle

Address

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Street

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City State Zip

Phone ( )

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Soc. Sec. # / / / / / / / / / / / /

Date of birth / / / / / / / / /

(Month Day Year)

Sex: / / Male / / Female

/ / Citizen of U.S.

/ / Resident Alien of U.S.

/ / Other

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5. BENEFICIARY

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PRIMARY

Name

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Last First Middle

Address

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Street

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City State Zip

/ / / / / / / / / / / /

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Relationship Social Security # (Optional)

CONTINGENT

Name

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Last First Middle

Address

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Street

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City State Zip

/ / / / / / / / / / / /

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Relationship Social Security # (Optional)

/ / ADDITIONAL BENEFICIARY INFORMATION ATTACHED.

Regardless of the beneficiary designation above, if upon the death of an

owner there is a surviving owner, the owner will be the beneficiary

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6. TYPE OF PLAN REQUESTED

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/ / NON-QUALIFIED

/ / QUALIFIED (check appropriate box)

/ / Standard IRA

/ / IRA Transfer from IRA

/ / IRA Rollover from IRA

/ / Direct Rollover

(IRA Rollover from Employer Plan)

/ / SEP-IRA (including SARSEP)

/ / 403(b) (TDA, TSA)

/ / KEY Plan (circle):

Profit Sharing Money Purchase

/ / Other Employer Qualified Plan

(Employer's name)

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/ / Other

(Employer's name)

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7. ANNUITIZATION

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The age lifetime income payments begin

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APPLICATION CONTINUES

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8. BILLING (Person or entity sending purchase payments for annuity)

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Name

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Last First Middle

Address

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Street

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City State Zip

/ / Send Bill / / Pre-Authorized Check-form attached

Will this be added to an existing retirement plan?

/ / Yes / / No If yes, please list:

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Employer name

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Employer address

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9. PURCHASE PAYMENT/PAYMENT ALLOCATION

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/ / Single Purchase Payment $

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/ / Additional Purchase Payments of $ per

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PAYMENT ALLOCATION: USE WHOLE %. MUST TOTAL 100%.

SUBACCOUNTS:

AGGRESSIVE GROWTH

% MFS Emerging

----- Growth

% Strong Discovery

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GROWTH

% Alliance Premier

----- Growth

% Montgomery Growth

-----

% TCI Growth

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INTERNATIONAL STOCK

% Alliance

----- International

% Lexington Emerging

----- Markets

% Montgomery

----- Emerging Markets

% Strong International

- -----

SPECIALTY

% Federated Utility

-----

% Lexington Natural

----- Resources

% Van Eck Gold and

----- Natural Resources

INTERNATIONAL BOND

% MFS World

----- Government

% Van Eck Worldwide

----- Bond

GROWTH & INCOME

% Federated American

----- Leaders

HIGH YIELD BOND

% Federated High

----- Income Bond

% MFS High Income

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BALANCED

% TCI Balanced

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CORPORATE BOND

% Strong Advantage

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GOVERNMENT BOND

% Strong Government

----- Bond

MONEY MARKET

% Alliance

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% FIXED ACCOUNT

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% Other

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MVA FIXED ACCOUNT

GUARANTEE PERIODS:

% 1 Year

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% 2 Year

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% 3 Year

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% 4 Year

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% 5 Year

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% 6 Year

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% 7 Year

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% 8 Year

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% 9 Year

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% 10 Year

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100 % TOTAL INCLUDES

----- BOTH COLUMNS

(If no allocations are indicated, the total purchase payment will be allocated

to the Money Market Subaccount.)

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10. REPLACEMENT

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Will this annuity replace or change any existing life insurance or annuity in

this or any other company?

/ / Yes / / No If yes, list insurance company.

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11. SPECIAL REQUESTS

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/ / Check if additional forms are attached.

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12. SUITABILITY

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(NOTE: Must be completed with each application unless you provide suitability

information to your broker/dealer on a different form.)

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Employer

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Business address

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City State Zip

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Occupation Age (optional)

Are you associated with or employed by an NASD member?

/ / Yes / / No

Estimated Annual Income $ ____________ / / Declined

(all sources)

Estimated Net Worth $ ____________ / / Declined

(exclusive of family residence)

Estimated Tax Bracket ____________% / / Declined

INVESTMENT OBJECTIVES:

/ / Safety of Principal

/ / Income (cash generating)

/ / Growth (long term capital appreciation)

/ / Diversification

/ / Other (please specify)

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Jack White & Company Account Number

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(if applicable)

APPLICATION CONTINUES

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I HEREBY REPRESENT MY ANSWERS TO THE PREVIOUS QUESTIONS TO BE TRUE TO THE BEST OF MY KNOWLEDGE. UNDER PENALTIES OF PERJURY, I CERTIFY THAT THE SOCIAL SECURITY NUMBER OR TAXPAYER IDENTIFICATION NUMBER SET FORTH ABOVE IS CORRECT. I

UNDERSTAND THAT ANNUITY PAYMENTS AND CONTRACT VALUES, WHEN BASED UPON THE

INVESTMENT EXPERIENCE OF A VARIABLE ACCOUNT, ARE NOT GUARANTEED. RECEIPT OF A

PROSPECTUS FOR THE ANNUITY PRODUCT HEREBY APPLIED FOR IS ACKNOWLEDGED.

ALL PAYMENTS AND VALUES BASED ON THE FIXED ACCOUNT ARE SUBJECT TO A MARKET VALUE ADJUSTMENT FORMULA, WHICH MAY RESULT IN UPWARD AND DOWNWARD ADJUSTMENTS IN AMOUNTS PAYABLE.

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13. REGISTERED REPRESENTATIVE STATEMENTS

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Will this annuity replace or change any existing life insurance or annuity in

this or any other company?

/ / Yes / / No

If yes, please explain and attach the necessary transfer paperwork and

replacement form.

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14. SIGNATURES

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Owner(s)

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Owner(s)

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Annuitant(s)

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Annuitant(s)

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Date

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State in which application is signed

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15. DEALER/REPRESENTATIVE INFORMATION

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Representative's name (please print)

Jack White & Company

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Name of Broker/Dealer

9191 Towne Centre Drive, San Diego, CA 92122

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Branch Office address

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Representative's signature

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Representative's number

(800) 622-3699

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Representative's phone number

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AUTHORIZED SIGNATURE OF BROKER/DEALER

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16. MAIL APPLICATION TO:

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Jack White & Company

Insurance Department

9191 Towne Centre Drive, Second Floor

San Diego, CA 92122

(800) 622-3699

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Make check payable to: [company name] Life Insurance Company

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VALUE - Super Low Costs

ADVANTAGE - Tax-Deferred Growth

PLUS - Choice of Professionally

Managed Portfolios

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VARIABLE ANNUITY APPLICATION