EX-99 2 app_ft0506.txt EX-5.k FIFTH THIRD PERSPECTIVE (05/06) JACKSON NATIONAL LIFE INSURANCE COMPANY(R)[GRAPHIC OMITTED] FIXED AND VARIABLE ANNUITY APPLICATION (VA220) Home Office: Lansing, Michigan WWW.JNL.COM See back page for mailing address. USE DARK INK, ONLY
------------------------------------------------------------------------------------------------------------------------------------ REGISTRATION INFORMATION ------------------------------------------------------------------------------------------------------------------------------------ OWNER'S NAME Date of Birth (mm/dd/yyyy) SSN/TIN (include dashes) ------------------------------------------------------------------------------------------------------------------------------------ Home Address (number and street) CITY, STATE, ZIP ------------------------------------------------------------------------------------------------------------------------------------ Age Sex U.S. Citizen Phone No. (include area code) E-Mail Address Broker/Dealer Account Number __ M __ F __ Yes __ No ------------------------------------------------------------------------------------------------------------------------------------ JOINT OWNER'S NAME (Proceeds will be distributed in accordance with the Contract SSN/TIN (include dashes) on the first death of either Owner. Spousal Joint Owner may continue the Contract.) ------------------------------------------------------------------------------------------------------------------------------------ Home Address (number and street) CITY, STATE, ZIP Relationship to Owner ------------------------------------------------------------------------------------------------------------------------------------ Date of Birth (mm/dd/yyyy) Age Sex U.S. Citizen Phone No. (include area code) E-Mail Address __ M __ F __ Yes __ No ------------------------------------------------------------------------------------------------------------------------------------ ANNUITANT'S NAME (if other than Owner) SSN/TIN (include dashes) ------------------------------------------------------------------------------------------------------------------------------------ Home Address (number and street) CITY, STATE, ZIP ------------------------------------------------------------------------------------------------------------------------------------ Date of Birth (mm/dd/yyyy) Age Sex U.S. Citizen Phone No. (include area code) E-Mail Address __ M __ F __ Yes __ No ------------------------------------------------------------------------------------------------------------------------------------ JOINT ANNUITANT'S NAME SSN/TIN (include dashes) ------------------------------------------------------------------------------------------------------------------------------------ Date of Birth (mm/dd/yyyy) Age Sex U.S. Citizen Phone No. (include area code) __ M __ F __ Yes __ No ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ BENEFICIARY DESIGNATION ------------------------------------------------------------------------------------------------------------------------------------ Percentages must equal 100% for each beneficiary type. For additional beneficiaries, please attach a separate sheet, signed and dated by the Owner, which includes names, percentages, and other required information. ------------------------------------------------------------------------------------------------------------------------------------ Name SSN/TIN (include dashes) Percentage (%) Primary --------------------------------------------------------------------------------------------------------------------- Relationship to Owner Address (number and street) City, State, ZIP ------------------------------------------------------------------------------------------------------------------------------------ __ Primary Name SSN/TIN (include dashes) Percentage (%) __ Contingent --------------------------------------------------------------------------------------------------------------------- Relationship to Owner Address (number and street) City, State, ZIP ------------------------------------------------------------------------------------------------------------------------------------ __ Primary Name SSN/TIN (include dashes) Percentage (%) __ Contingent --------------------------------------------------------------------------------------------------------------------- Relationship to Owner Address (number and street) City, State, ZIP ------------------------------------------------------------------------------------------------------------------------------------ __ Primary Name SSN/TIN (include dashes) Percentage (%) __ Contingent --------------------------------------------------------------------------------------------------------------------- Relationship to Owner Address (number and street) City, State, ZIP ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ANNUITY TYPE TRANSFER INFORMATION ------------------------------------------------------------------------------------------------------------------------------------ __ Non-Tax Qualified __ IRA - Individual* __ IRC 1035 Exchange __ 401(k) Qualified Savings Plan __ IRA - Custodial __ Direct Transfer __ HR-10 (Keogh) Plan __ IRA - Roth* __ Direct Rollover __ 403(b) TSA (Direct Transfer Only) *Tax Contribution Years and Amounts: __ Non-Direct Rollover __ IRA - SEP Year:______ $______ __ Roth Conversion __ Other ___________________________ Year:______ $______ ------------------------------------------------------------------------------------------------------------------------------------ ARIZONA RESIDENTS, PLEASE NOTE: RIGHT TO EXAMINE. On written request, the Company will provide to the contract Owner, within a reasonable time, reasonable factual information regarding the benefits and provisions of this Contract. If, for any reason, the contract Owner is not satisfied, the Contract may be returned to the Company or agent within 10 days (30 days if YOU WERE AGE 65 OR OLDER ON THE DATE THE APPLICATION WAS SIGNED or it was purchased as a replacement contract) after delivery and the Contract Value, without deductions for any sales charges for the business day on which the Contract is received at its Service Center, will be returned. VDA 120 FT4173 05/06 ------------------------------------------------------------------------------------------------------------------------------------ REPLACEMENT * Must be completed for "Good Order" ------------------------------------------------------------------------------------------------------------------------------------ *ARE YOU REPLACING AN EXISTING LIFE INSURANCE POLICY OR ANNUITY CONTRACT? ___ YES ___ NO IF "YES", PLEASE COMPLETE THIS SECTION. ------------------------------------------------------------------------------------------------------------------------------------ Company Name Contract No. Anticipated Transfer Amount $ ------------------------------------------------------------------------------------------------------------------------------------ Company Name Contract No. Anticipated Transfer Amount $ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ OPTIONAL DEATH BENEFITS ALL OPTIONAL DEATH BENEFITS MAY NOT BE AVAILABLE IN ALL STATES AND ONCE SELECTED CANNOT BE CHANGED. ------------------------------------------------------------------------------------------------------------------------------------ If no Optional Death Benefit is selected your beneficiary(ies) will receive the standard death benefit. Please see the prospectus for details. Please select only one option: 1. ___ 5% Roll-Up Death Benefit (4% if the Owner is age 70 or older on the date of issue) 2. ___ 4% Roll-Up Death Benefit (3% if the Owner is age 70 or older on the date of issue) 3. ___ Highest Anniversary Value Death Benefit 4. ___ Combination of Options 1 and 3 above. 5. ___ Combination of Options 2 and 3 above. ADDITIONAL CHARGES WILL APPLY. PLEASE SEE THE PROSPECTUS FOR DETAILS. ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ OTHER OPTIONAL BENEFITS ALL OPTIONAL BENEFITS MAY NOT BE AVAILABLE IN ALL STATES AND ONCE SELECTED CANNOT BE CHANGED. ------------------------------------------------------------------------------------------------------------------------------------ A. EARNINGS PROTECTION BENEFIT __ EarningsMax(SM) B. CONTRACT ENHANCEMENT OPTIONS (MAY SELECT ONLY ONE) __ 2% of first-year premium __ 3% of first-year premium __ 4% of first-year premium C. WITHDRAWAL OPTIONS __ 20% Free Withdrawal Benefit (1) __ 5-Year Withdrawal Charge Schedule D. GUARANTEED LIVING BENEFIT OPTIONS (MAY SELECT ONLY ONE) GUARANTEED MINIMUM INCOME BENEFIT OPTION __ FutureGuard(SM) GUARANTEED MINIMUM WITHDRAWAL BENEFIT (GMWB) OPTIONS __ SafeGuard 7 Plus(SM) (7% GMWB) __ AutoGuard(SM) (5% GMWB with Annual Step-Up) __ MarketGuard 5(SM) (5% GMWB) __ LifeGuard Protector Advantage(SM) (5% For Life GMWB with Bonus and Annual Step-Up) __ LifeGuard Protector(SM) (5% For Life GMWB with Annual Step-Up) __ LifeGuard Protector with Joint Option(SM) (2) (Joint 5% For Life GMWB with Annual Step-Up) __ LifeGuard Protector Plus(SM) (5% For Life GMWB with Bonus and 5-Year Step-Up) __ LifeGuard Protector Plus with Joint Option(SM) (2) (Joint 5% For Life GMWB with Bonus and 5-Year Step-Up) ADDITIONAL CHARGES WILL APPLY. PLEASE SEE THE PROSPECTUS FOR DETAILS. (1) May not be selected in combination with either the 3% or 4% Contract Enhancement. (2) Spousal joint ownership required and available on Nonqualified Plans only. Please ensure the Joint Ownership section on Page 1 (including the "Relationship to Owner" box) is properly completed. ----------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- INITIAL PREMIUM INCOME DATE ----------------------------------------------------------------------------------------------------------------------------- Amount of premium with application: $__________________ PLEASE SPECIFY DATE (mm/dd/yyyy):__________________ MAKE ALL CHECKS PAYABLE TO JACKSON NATIONAL LIFE INSURANCE COMPANY(R) If an Income Date is not specified, age 90 (age 70 1/2 for Qualified Plans) of the Owner will be used. ----------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- CAPITAL PROTECTION PROGRAM ----------------------------------------------------------------------------------------------------------------------------- __ Yes __ No If "No", please proceed to the Premium Allocation Section. (If no selection is made, JNL will default to "No.") If you marked "Yes", which Fixed Account Option do you wish to select for the Capital Protection Program? SELECT ONLY ONE. __ 1-Year __ 3-Year __ 5-Year __ 7-Year Now that you have selected a Fixed Account Option for the Capital Protection Program, indicate how you would like the balance of your initial premium allocated using the Premium Allocation Section on the following page. ----------------------------------------------------------------------------------------------------------------------------- Page 2 of 5 VDA 120 FT4173 05/06 ------------------------------------------------------------------------------------------------------------------------------------ TOTAL NUMBER OF ALLOCATIONS MAY NOT EXCEED 18 PREMIUM ALLOCATION WHOLE PERCENTAGES ONLY * TOTAL ALLOCATION MUST EQUAL 100% ------------------------------------------------------------------------------------------------------------------------------------ NUMBER PORTFOLIOS NUMBER PORTFOLIOS 205 __% Fifth Third Disciplined Value VIP 096 __% JNL/Mellon Capital Management Dow Dividend 204 __% Fifth Third Mid Cap VIP 225 __% JNL/Mellon Capital Management VIP 202 __% Fifth Third Quality Growth VIP 191 __% JNL/Mellon Capital Management Communications Sector 203 __% Fifth Third Balanced VIP 185 __% JNL/Mellon Capital Management Consumer Brands Sector 196 __% JNL(R)/AIM Large Cap Growth 189 __% JNL/Mellon Capital Management Financial Sector 206 __% JNL/AIM Real Estate 188 __% JNL/Mellon Capital Management Healthcare Sector 195 __% JNL/AIM Small Cap Growth 190 __% JNL/Mellon Capital Management Oil & Gas Sector 114 __% JNL/Alger Growth 187 __% JNL/Mellon Capital Management Technology Sector 115 __% JNL/Eagle Core Equity 054 __% JNL/Mellon Capital Management Enhanced S&P 500 Stock 116 __% JNL/Eagle SmallCap Equity Index 150 __% JNL/FMR Balanced 173 __% JNL/Oppenheimer Global Growth 101 __% JNL/FMR Mid-Cap Equity 174 __% JNL/Oppenheimer Growth 075 __% JNL/Franklin Templeton Income 127 __% JNL/PIMCO Total Return Bond 208 __% JNL/Franklin Templeton Small Cap Value 105 __% JNL/Putnam Equity 207 __% JNL/Goldman Sachs Mid Cap Value 148 __% JNL/Putnam Midcap Growth 076 __% JNL/Goldman Sachs Short Duration Bond 106 __% JNL/Putnam Value Equity 113 __% JNL/JPMorgan International Equity 104 __% JNL/Select Balanced 126 __% JNL/JPMorgan International Value 103 __% JNL/Select Global Growth 077 __% JNL/Lazard Emerging Markets 102 __% JNL/Select Large Cap Growth 132 __% JNL/Lazard Mid Cap Value 107 __% JNL/Select Money Market 131 __% JNL/Lazard Small Cap Value 179 __% JNL/Select Value 123 __% JNL/Mellon Capital Management S&P 500(R) Index 111 __% JNL/T. Rowe Price Established Growth 124 __% JNL/Mellon Capital Management S&P(R) 400 112 __% JNL/T. Rowe Price Mid-Cap Growth MidCap Index 149 __% JNL/T. Rowe Price Value 128 __% JNL/Mellon Capital Management Small Cap Index 136 __% JNL/Western High Yield Bond 129 __% JNL/Mellon Capital Management International Index 110 __% JNL/Western Strategic Bond 133 __% JNL/Mellon Capital Management Bond Index 109 __% JNL/Western U.S. Government & Quality Bond 145 __% JNL/Mellon Capital Management Dow(SM) 10 193 __% JNL/Mellon Capital Management S&P 10 FIXED ACCOUNT OPTIONS 183 __% JNL/Mellon Capital Management Global 15 041 __% 1-year 045 __% 5-year 184 __% JNL/Mellon Capital Management 25 043 __% 3-year 047 __% 7-year 186 __% JNL/Mellon Capital Management Select Small-Cap 224 __% JNL/Mellon Capital Management JNL 5 IF THE USE OF THE MODEL PORTFOLIOS ARE INTENDED, PLEASE 079 __% JNL/Mellon Capital Management JNL Optimized 5 REFER TO FORM FT2385. 222 __% JNL/Mellon Capital Management Nasdaq(R) 15 074 __% JNL/Mellon Capital Management S&P(R) 24 DCA+ ($15,000 CONTRACT MINIMUM) 223 __% JNL/Mellon Capital Management Value Line(R) 25 030 __% 6-month IF DCA+ IS SELECTED, YOU MUST ATTACH 032 __% 12-month THE SYSTEMATIC INVESTMENT FORM (FT2375). __ CHECK HERE FOR AUTOMATIC REBALANCING. Only the Portfolios selected above and the 1-year Fixed Account (if selected) will DCA+ provides an automatic monthly transfer to the selected participate in the program. The 3-, 5- and 7-year Fixed Accounts Portfolio(s) so the entire amount invested in this program, are not available for Automatic Rebalancing. plus earnings, will be transferred by the end of the DCA+ term selected. Frequency: __ Monthly __ Quarterly __Semi-Annual __ Annual Start Date:______________________ If no date is selected, the program will begin one month/ quarter/half year/year (depending on the frequency you selected) from the date JNL applies the first premium payment. ---------------------------------------------------------------------------- ALL PREMIUM ALLOCATION OPTIONS MAY NOT BE AVAILABLE IN ALL STATES. RESTRICTIONS MAY APPLY AT JNL'S DISCRETION ON A NON-DISCRIMINATORY BASIS. ---------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------ Page 3 of 5 VDA 120 FT4173 05/06 -------------------------------------------------------------------------------- TELEPHONE/ELECTRONIC TRANSFERS AUTHORIZATION -------------------------------------------------------------------------------- DO YOU WISH TO AUTHORIZE THESE TYPES OF TRANSFERS? ___ Yes ____ No By checking "Yes", I (We) authorize Jackson National Life(R) (JNL) to accept fund transfers/allocation changes via telephone, Internet, or other electronic medium from me (us) and my (our) Representative subject to JNL's administrative procedures. JNL's administrative procedures are designed to provide reasonable assurances that telephone/electronic authorizations are genuine. If JNL fails to employ such procedures, it may be held liable for losses resulting from a failure to use such procedures. I (We) agree that JNL, its affiliates, and subsidiaries shall not be liable for losses incurred in connection with telephone/electronic instructions received, and acted on in good faith, notwithstanding subsequent allegations of error or mistake in connection with any such transaction instruction. IF NO ELECTION IS MADE, JNL WILL DEFAULT TO "NO" FOR RESIDENTS OF NORTH DAKOTA AND TO "YES" FOR RESIDENTS OF ALL OTHER STATES. -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- ELECTRONIC RECEIPT OF STATEMENTS/CORRESPONDENCE -------------------------------------------------------------------------------- I consent ___ I do not consent ___ to electronic delivery of annual and semi-annual reports, quarterly and immediate confirms, prospectuses and prospectus supplements, and related correspondence (except ______________________) from Jackson National Life, when available. There is no charge for electronic delivery. Please make certain you have given us a current e-mail address. Also let us know if that e-mail address changes as we will need to notify you of a document's availability through e-mail. To view an electronic document, you will need Internet access. You may request paper copies, whether or not you also decide to revoke your consent for electronic delivery, at any time and for no charge. Please contact the appropriate JNL Service Center to update your e-mail address, revoke your consent to electronic delivery, or request paper copies. -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- IMPORTANT - PLEASE READ CAREFULLY. -------------------------------------------------------------------------------- 1. I (We) hereby represent to the best of my (our) knowledge and belief that each of the statements and answers contained in this application are true, complete and correctly recorded. 2. I (We) certify that the Social Security or Taxpayer Identification number(s) shown above is (are) correct. 3. I (WE) UNDERSTAND THAT ANNUITY BENEFITS AND WITHDRAWAL VALUES, IF ANY, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A PORTFOLIO IN THE SEPARATE ACCOUNT OF JNL ARE VARIABLE AND MAY BE INCREASED OR DECREASED, AND THE DOLLAR AMOUNTS ARE NOT GUARANTEED. 4. I (We) have been given a current prospectus for this variable annuity and for each available portfolio. 5. The contract I (We) have applied for is suitable for my (our) insurance and investment objectives, financial situation and needs. 6. I understand the restrictions imposed by 403(b)(11) of the Internal Revenue Code. I understand the investment alternatives available under my employer's 403(b) plan, to which I may elect to transfer my contract value. 7. I (WE) UNDERSTAND THAT ALLOCATIONS TO THE FIXED ACCOUNT OPTIONS ARE SUBJECT TO AN ADJUSTMENT IF WITHDRAWN OR TRANSFERRED PRIOR TO THE END OF THE APPLICABLE PERIOD, WHICH MAY REDUCE AMOUNTS WITHDRAWN OR TRANSFERRED. -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- SIGNATURES * Must be completed for "Good Order" -------------------------------------------------------------------------------- SIGNED AT * (city, state) DATE SIGNED * (mm/dd/yyyy) -------------------------------------------------------------------------------- Owner's Signature Annuitant's Signature (if other than Owner) -------------------------------------------------------------------------------- Joint Owner's Signature Joint Annuitant's Signature (if other than Joint Owner) -------------------------------------------------------------------------------- Page 4 of 5 VDA 120 FT4173 05/06 -------------------------------------------------------------------------------- PRODUCER/REPRESENTATIVE'S STATEMENT -------------------------------------------------------------------------------- I certify that: I am authorized and qualified to discuss the contract herein applied for; I have fully explained the contract to the client, including contract restrictions and charges; I believe this transaction is suitable given the client's financial situation and needs; I have complied with requirements for disclosures and/or replacements as necessary; and to the best of my knowledge and belief the applicant's statement as to whether or not an existing life insurance policy or annuity contract is being replaced is true and accurate. (If a replacement, please provide a replacement form or other special forms where required by state law.) ---------------------------------------------------------------------------------------------------------------- Producer/Representative's Full Name (please print) Phone No. (include area code) ---------------------------------------------------------------------------------------------------------------- Producer/Representative's Signature Date Signed (mm/dd/yyyy) ---------------------------------------------------------------------------------------------------------------- Address (number and street) City, State, ZIP ---------------------------------------------------------------------------------------------------------------- E-Mail Address Contact your home office for program information. __ Option A __ Option B __ Option C __ Option D __ Option E ---------------------------------------------------------------------------------------------------------------- Broker/Dealer Name Broker/Dealer Representative No. JNL Producer/Representative No. ----------------------------------------------------------------------------------------------------------------
ARKANSAS, COLORADO, DISTRICT OF COLUMBIA, KENTUCKY, LOUISIANA, MAINE, NEW MEXICO, OHIO, OKLAHOMA, PENNSYLVANIA, TENNESSEE, AND WEST VIRGINIA RESIDENTS, PLEASE NOTE: Any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. In COLORADO, any insurance company, or agent of an insurance company, who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding, or attempting to defraud, the policyholder or claimant with regard to a settlement or award payable from insurance proceeds, shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. FLORIDA RESIDENTS: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, files a statement of claim or an application containing any false, incomplete or misleading information, is guilty of a felony of the third degree. -------------------------------------------------------------------------------- MAILING ADDRESS AND CONTACT INFORMATION -------------------------------------------------------------------------------- REGULAR MAIL: Jackson National Life(R)/IMG Service Center, P.O. Box 30392, Lansing, MI 48909-7892 OVERNIGHT MAIL: Jackson National Life/IMG Service Center, 1 Corporate Way, Lansing, MI 48951 CUSTOMER CARE: 800/777-7779 (8:00 a.m. to 8:00 p.m. ET) or contactus@jnli.com FAX: 517/706-5540 -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Not FDIC/NCUA insured * Not Bank guaranteed * May lose value Not a deposit * Not insured by any federal agency -------------------------------------------------------------------------------- Page 5 of 5 VDA 120 FT4173 05/06