INDIVIDUAL VARIABLE ANNUITY APPLICATION

CONTRACT #

Select Product: X Protective Dimensions IV Variable Annuity

Exhibit (e)(1)(i)

PROTECTIVE LIFE INSURANCE COMPANY

Send Applications to:

Overnight: 2801 Highway 280 South, Birmingham, Alabama 35223

U.S. Mail: P. O. Box 10648, Birmingham, Alabama 35202-0648
(800) 456-6330

Owner 1 (If mailing address is a P.O. Box, please provide a physical address in the 'Remarks' area.)

Name:

Male Female

Address:

Birthdate:

City:

State:

Zip:

SSN/Tax ID:

Email Address:

Phone:

Owner 2 (If applicable.)

Name:

Male Female

Address:

Birthdate:

City:

State:

Zip:

SSN/Tax ID:

Email Address:

Phone:

Annuitant Same as Owner 1 Same as Owner 2
(If not Owner 1 or 2, complete this section.)

Name:

Male Female

Address:

Birthdate:

City:

State:

Zip:

SSN/Tax ID:

Email Address:

Phone:

Beneficiary, if there is no surviving Owner

Use Administrative Form LAD-1225 to name or change a beneficiary any time before the death of an owner.

Initial Purchase Payment: $

(minimum: $10,000)

Funding Source:

Cash

Non-Qualified 1035 Exchange

CD/Non-Insurance Exchange

Direct Transfer

Direct Rollover

Indirect Rollover

Plan Type:

Non-Qualified

IRA

Roth IRA

Other:

Complete if an IRA and includes new contributions:

(Amount)

(Tax Year)

(Amount)

(Tax Year)

Replacement:

Do you currently have an annuity contract or life insurance policy?

Yes No

Will this annuity change or replace an existing annuity contract or life insurance policy?

Yes No

(If yes, please provide the company name and contract or policy number below.)

Company 1		Contract or Policy #
Company 2		Contract or Policy #
Company 3		Contract or Policy #

An annuity contract is not a deposit or obligation of, nor guaranteed by any bank or financial institution. It is not insured by the Federal Deposit Insurance Corporation or any other government agency, and is subject to investment risk, including the possible loss of principal.

CONTRACT BENEFITS ARE VARIABLE, MAY INCREASE OR DECREASE, AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT.

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Dimensions IV 5/22

INDIVIDUAL VARIABLE ANNUITY APPLICATION

CONTRACT #

PROTECTIVE LIFE INSURANCE COMPANY

ALLOCATE PURCHASE PAYMENTS – Allocation instructions remain in effect until you change them. Use whole percentages. ‘Purchase Payment’ and ‘DCA Allocation’ percentage totals must equal 100%, each. If using a Model Portfolio, allocate to the Guaranteed Account and one Model Portfolio, only.

If you are purchasing a protected lifetime income benefit your contract allocation is restricted to a single choice from among the following three options:

•

100% to the Clayton Street Protective Life Dynamic Allocation Series – Conservative Sub-Account; or

•

100% to the Clayton Street Protective Life Dynamic Allocation Series – Moderate Sub-Account; or

•

50% to the Clayton Street Protective Life Dynamic Allocation Series – Moderate Sub-Account and 50% to the Balanced Growth & Income Model Portfolio

Dollar Cost Averaging from a DCA Account into one of these allocations is permitted.

Protective Life Guaranteed Account

Purchase Payment

Investment Option

Guaranteed Account – not available if you purchase a protected lifetime income benefit

DCA Account 1 – Make DCA transfers on the day (1st – 28th) of the month for months (3 – 6 months) .

DCA Account 2 – Make DCA transfers on the day (1st – 28th) of the month for months (3 – 6 months) .

Sub-Accounts of the Protective Variable Annuity Separate Account

Purchase
Payment

DCA
Allocation

Manager

Investment Options

AllianceBernstein

Growth and Income

AllianceBernstein

Large Cap Growth

AllianceBernstein

Small Cap Growth

AllianceBernstein

Small/Mid Cap Value

American Funds

American High-Income

American Funds

Asset Allocation

American Funds

Capital Income Builder

American Funds

Capital World Bond

American Funds

Capital World Growth and Income

American Funds

Global Growth

American Funds

Global Small Capitalization

American Funds

Growth

American Funds

Growth-Income

American Funds

International

American Funds

International Growth and Income

American Funds

New World

American Funds

The Bond Fund of America

American Funds

U.S. Government Securities

American Funds

Washington Mutual Investors

BlackRock Advisors

60/40 Target Allocation

BlackRock Advisors

Global Allocation

BlackRock Advisors

International

Columbia Management

Balanced

Columbia Management

Emerging Markets Bond

Columbia Management

Limited Duration Credit

Columbia Management

Select Mid Cap Value

Columbia Management

Strategic Income

Fidelity Management & Research

Asset Manager

Fidelity Management & Research

Asset Manager Growth

Fidelity Management & Research

Balanced

Fidelity Management & Research

Bond Index

Fidelity Management & Research

Energy

Fidelity Management & Research

Extended Market Index

Fidelity Management & Research

FundsManager 60%

Fidelity Management & Research

FundsManager 85%

Fidelity Management & Research

Health Care

Fidelity Management & Research

Index 500

Fidelity Management & Research

International Index

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Dimensions IV 5/22

INDIVIDUAL VARIABLE ANNUITY APPLICATION

CONTRACT #

PROTECTIVE LIFE INSURANCE COMPANY

Sub-Accounts of the Protective Variable Annuity Separate Account (continued)

Purchase
Payment

DCA
Allocation

Manager

Investment Options

Fidelity Management & Research

Investment Grade Bond

Fidelity Management & Research

Mid Cap

Fidelity Management & Research

Technology

Fidelity Management & Research

Total Market Index

Fidelity Management & Research

Utilities

Fidelity Management & Research

Value Strategies

Franklin Templeton Investments

ClearBridge Mid Cap

Franklin Templeton Investments

ClearBridge Small Cap Growth

Franklin Templeton Investments

Franklin Dynatech

Franklin Templeton Investments

Franklin Income

Franklin Templeton Investments

Franklin Rising Dividends

Franklin Templeton Investments

Franklin Small Cap Value

Franklin Templeton Investments

Franklin Small-Mid Cap Growth

Franklin Templeton Investments

Templeton Developing Markets

Goldman Sachs Asset Management

Core Fixed Income

Goldman Sachs Asset Management

Mid Cap Growth

Goldman Sachs Asset Management

Strategic Growth

Invesco Advisers

Conservative Balanced

Invesco Advisers

Discovery Mid Cap Growth

Invesco Advisers

Equity and Income

Invesco Advisers

Global

Invesco Advisers

Global Real Estate

Invesco Advisers

Government Securities

Invesco Advisers

Main Street Small Cap

Invesco Advisers

Small Cap Equity

Invesco Advisers

U.S. Government Money

Janus

Clayton Street Protective Life Dynamic Allocation Series – Conservative

Janus

Clayton Street Protective Life Dynamic Allocation Series – Moderate

Janus

Clayton Street Protective Life Dynamic Allocation Series – Growth

Lord Abbett

Bond Debenture

Lord Abbett

Dividend Growth

Lord Abbett

Growth Opportunities

Lord Abbett

Short Duration Income

PIMCO

Low Duration

PIMCO

Real Return

PIMCO

Short-Term

PIMCO

Total Return

T. Rowe Price

All-Cap Opportunities

T. Rowe Price

Blue Chip Growth

T. Rowe Price

Health Sciences

T. Rowe Price

Moderate Allocation

Protective Life Model Portfolios

Purchase
Payment

DCA
Allocation

Purchase
Payment

DCA
Allocation

Conservative Growth

Balanced Growth

Balanced Growth and Income

Growth Focus

Transfer Authorization

I authorize the Company to honor my telephone and/or digital instructions for transfers among the investment options.

I authorize the Company to honor my agent’s instructions for transfers among the investment options.

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Dimensions IV 5/22

INDIVIDUAL VARIABLE ANNUITY APPLICATION

CONTRACT #

PROTECTIVE LIFE INSURANCE COMPANY

OPTIONAL BENEFITS AND FEATURES - Select the options to be included in your contract, and complete any additional required forms.

Optional Management Tools Available Without Charges or Fees

Automatic Purchase Plan – Complete form LAD-1128. Not available if Partial Automatic Withdrawals are selected.

Partial Automatic Withdrawals – Complete forms LAD-1147 and LAD-1133. Not available if Automatic Purchase Plan is selected.

Portfolio Rebalancing – Required, if SecurePay FXi is selected.

Rebalance to my current Variable Account allocation quarterly semi-annually annually on the day (1st – 28th) of the month.

Optional Benefits Offered with a Separate, Additional Charge or Fee

Enhanced Death Benefits – Do not select more than one enhanced death benefit.

Maximum Anniversary Value Death Benefit - Not available if any Owner or Annuitant is age 78 or older.

Maximum Quarterly Value Death Benefit - Not available if any Owner or Annuitant is age 78 or older.

Protected Lifetime Income Benefit

SecurePay FXi - Not available if any Owner or Annuitant is younger than age 55 or older than age 80.

SUITABILITY

Did you receive an Annuity Buyers Guide and a current prospectus for this annuity?

Yes No

Do you believe the annuity meets your financial needs and objectives?

Yes No

APPLICANT SIGNATURES

I understand this application will be part of the annuity contract. I have read the completed application and confirm that the information it contains is true and correct to the best of my knowledge and belief. However, these statements are representations and not warranties. If this application includes two Owners, the company may accept instructions from either Owner on behalf of both Owners.

Variable annuities involve risk, including the possible loss of principal. The Contract Value, annuity payments and termination values, when based upon the investment experience of the separate account, are variable and are not guaranteed as to any fixed dollar amount.

ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.

Application signed at: on

(City and State)

(Date)

Owner’s Signature

Joint Owner’s Signature (if applicable)

Annuitant’s Signature (if not an Owner)

Federal law requires the following notice: We may request or obtain additional information to establish or verify your identity.

Remarks:

PRODUCER REPORT - This section must be completed and signed by the agent for the Contract to be issued.

To the best of your knowledge and belief…

Does the applicant have any existing annuity contract or life insurance policy?

Yes No

Does this annuity change or replace any existing annuity contract or life insurance policy?

Yes No

Type of unexpired government issued photo I.D. used to verify applicant’s identity:

I have determined this annuity is suitable based on information I obtained from the applicant after reasonable inquiry into their financial and tax status, investment objectives, and other relevant information.

I certify that I have truly and accurately recorded on this application the information provided to me by the applicant.

Agent Signature:

Print Agent Name:

Agent #

Brokerage:

State Agent License #

Phone #

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Dimensions IV 5/22

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