Exhibit

EX-99.5 4 ex995applicationmas.htm EXHIBIT 99.5 Exhibit

FORTIS BENEFITS INSURANCE COMPANY

INDIVIDUAL MVA VARIABLE ANNUITY APPLICATION

[PRODUCT NAME HERE]

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1. OWNER

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Name Doe John J

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Last First Middle

Address 123 Anytime Avenue

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Street

Anyday MN 54321

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City State Zip

Phone 612-000-0000

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SOC. SEC. # 123-45-6789 /x/ Citizen of U.S.

-------------------------------------------------------------------- / / Resident Alien

of U.S.

DATE OF BIRTH 11-22-62 / / Other

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Sex: /X/ Male / / Female ---------------------------------

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2. CO-OWNER (optional)

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Name

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Last First Middle

Address ------------------------------------------------------------------------------------------------------------------------------------

Street

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City State Zip

Phone -----------------------------------------------------------------------------------------------------------------------------------

SOC. SEC. # ------------------------------------------------------------------------ / / Citizen of U.S.

/ / Resident Alien

of U.S.

DATE OF BIRTH --------------------------------------------------------------------- / / Other

Sex: / / Male / / Female

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3. ANNUITANT (if other than participant)

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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. # / / Citizen of U.S.

------------------------------------------------------------------------------------------ / / Resident Alien

of U.S.

DATE OF BIRTH / / Other

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Sex: / / Male / / Female

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4. ADDITIONAL ANNUITANT (optional)

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Name

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Last First Middle

Address ------------------------------------------------------------------------------------------------------------------------------------

Street

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City State Zip

Phone

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SOC. SEC. # / / Citizen of U.S.

------------------------------------------------------------------------------------------ / / Resident Alien

of U.S.

DATE OF BIRTH / / Other

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Sex: / / Male / / Female

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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

Phone

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SOC. SEC. # / / Citizen of U.S.

------------------------------------------------------------------------------------------ / / Resident Alien

of U.S.

DATE OF BIRTH / / Other

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Sex: / / Male / / Female

Spouse 987-65-4321

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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

Phone

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SOC. SEC. # / / Citizen of U.S.

------------------------------------------------------------------------------------------ / / Resident Alien

of U.S.

DATE OF BIRTH / / Other

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Sex: / / Male / / Female

Daughter ###-##-####

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Relationship Social Security # (Optional)

/ / ADDITIONAL BENEFICIARY INFORMATION ATTACHED.

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6. TYPE OF PLAN REQUESTED

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For annual IRA contributions, indicate on the check the year for which the contribution is made.

/ / NON-QUALIFIED

/ / QUALIFIED (check appropriate box)

/ / Traditional IRA / / Roth IRA

/ / Direct Transfer / / Direct Transfer

/ / Rollover / / Rollover

/ / Direct Rollover

(IRA Rollover from Employer Plan)

/ / SEP-IRA (including SARSEP)

/ / 403(b) (TDA, TSA)

/ / KEY Plan

(complete and attach First Trust Key Plan document):

/ / Profit Sharing / / Money Purchase

/ / SIMPLE IRA

/ / Other Employer Qualified Plan

(Employer's Name)

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/ / Other

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(Employer's Name)

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7. ANNUITIZATION

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The age of the Annuitant at which lifetime income payments begin: 70

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8. TELEPHONE TRANSFER AUTHORIZATION

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/ / I have read the telephone transfer authorization terms in the prospectus and elect telephone transfers.

(If this box is checked it is not necessary to complete the telephone transfer section of the Variable Annuity Service Request

Form.)

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APPLICATION CONTINUES

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42368

<PAGE>

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

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Name

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Last First Middle

Address ------------------------------------------------------------------------------------------------------------------------------------

Street

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City State Zip

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

Will this be added to an existing retirement plan?

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

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Employer name

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Employer address

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10. 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%

_____% 204 Money Market

_____% 205 U.S. Government Securities

_____% 201 Diversified Income

_____% 212 Global Bond (Mercury)

_____% 209 High Yield

_____% 210 Global Asset Allocation (Morgan Stanley)

_____% 203 Asset Allocation

_____% 213 Value

_____% 208 Growth & Income

_____% 214 S&P 500 Index (Dreyfus)

_____% 215 Blue Chip Stock (T. Rowe Price)

_____% 211 International Stock (Lazard Freres)

_____% 216 MidCap Stock Series (Dreyfus)

_____% 218 Small Cap Value Series (Berger)

_____% 206 Global Growth

_____% 217 Large Cap Growth Series (Alliance)

_____% 202 Growth Stock

_____% 207 Aggressive Growth

_____% ____________________

_____% Other_______________

MVA FIXED ACCOUNT

GUARANTEE PERIODS:

_____% 1 Year _____% 5 Year _____% 9 Year

_____% 2 Year _____% 6 Year _____% 10 Year

_____% 3 Year _____% 7 Year _100_% TOTAL

_____% 4 Year _____% 8 Year (Includes all columns.)

(If no allocations are indicated, the total purchase payment will be allocated to the Money Market Subaccount.)

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11. REPLACEMENT

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Will this annuity replace or change any existing life insurance or annuity in this or any other company?

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

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12. SPECIAL REQUESTS

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/ / Check if additional forms are attached.

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13. 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

123 Honeywell Street

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Business address

Anyday MN 54321

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City State Zip

Packager 35

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Occupation Age

Are you associated with or employed by an NASD member?

/ / Yes /X/ No

Estimated Annual Income $50,000 / /

Declined (all sources) ---------

Estimated Net Worth $ / /

Declined (exclusive of family residence) ---------

Estimated Tax Bracket % / /

Declined ---------

INVESTMENT OBJECTIVES:

/ / Safety of Principal

/ / Income (cash generating)

/X/ Growth (long term capital appreciation)

/ / Diversification

/ / Other (please specify)

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I hereby represent my answers to the above questions to be true to the best of my knowledge. I UNDERSTAND THAT ANNUITY PAYMENTS AND CONTRACT VALUES UNDER THE VARIABLE ACCOUNT PROVISIONS OF THE CONTRACT BEING APPLIED FOR ARE VARIABLE, AND ARE NOT GUARANTEED AS TO THE DOLLAR AMOUNT. Receipt of a prospectus for the annuity product hereby applied for is acknowledged. All payments and value based on the fixed account are subject to a market value adjustment formula, which may result in upward and downward adjustments in amounts payable.

If I live in a community property state, I may need my spouse's written consent whenever I name a person other than my spouse as my beneficiary. I am responsible to know if consent is needed and to obtain consent if required.

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APPLICATION

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14. 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 /X/ No

If yes, please attach a Client Replacement Disclosure Letter (Form 99134) with any other necessary transfer paperwork and state replacement form, if required.

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/ / Please check if:

Your client qualifies for exemption from the surrender charge because they are included in one of the categories listed under the exemption terms in the prospectus; and you waive commissions on this annuity.

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15. SIGNATURES

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(For Minnesota residents) I hereby acknowledge receipt of the Minnesota Guaranty Association Disclosure Notice.

/s/ John Doe

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Owner(s)

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Owner(s)

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Annuitant(s)

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Annuitant(s)

May 1, 1998

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Date

Anystate

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State in which application is signed

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16. DEALER/REPRESENTATIVE INFORMATION

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Representative's name (please print)

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Name of Broker/Dealer

1414 Mockingbird Lane, Anyday, MN 54321

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Branch Office address

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Representative's signature

67845

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Representative's number

612-738-8991

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Representative's phone number

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(In Florida, also present a Florida license I.D. #)

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Authorized signature of Broker/Dealer

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17. MAIL APPLICATION TO:

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APPLICATIONS WITH PAYMENT:

Fortis Benefits Insurance Company

CM-9709

St. Paul, Minnesota 55107-9709

APPLICATIONS WITHOUT PAYMENT:

Fortis Benefits Insurance Company

P.O. Box 64272

St. Paul, Minnesota 55164

FOR OVERNIGHT DELIVERY:

Fortis Benefits Insurance Company

500 Bielenberg Drive

Woodbury, Minnesota 55125

Attn: Annuities

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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 fines and confinement in prison.

Make check payable to: Fortis Benefits Insurance Company