EX-99 2 app_ft0507.txt EX-5.o FIFTH THIRD PERSPECTIVE(R) (05/07) JACKSON(SM) NATIONAL LIFE INSURANCE COMPANY FIXED AND VARIABLE ANNUITY APPLICATION (VA220) Home Office: Lansing, Michigan WWW.JNL.COM See back page for mailing address. USE DARK INK ONLY - ALL PAGES MUST BE COMPLETED FOR "GOOD ORDER"
---------------------------------------------------------------------------- External Account No. (if applicable) Trade No. (if applicable) ---------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------ REGISTRATION INFORMATION ------------------------------------------------------------------------------------------------------------------------------------ OWNER'S NAME (IF OWNED BY A NON-NATURAL ENTITY) ------------------------------------------------------------------------------------------------------------------------------------ OWNER'S NAME (FIRST) (MIDDLE) (LAST) Date of Birth (mm/dd/yyyy) ___ SSN ___ TIN (include dashes) ------------------------------------------------------------------------------------------------------------------------------------ Home Address (Physical Address Required) CITY STATE ZIP ------------------------------------------------------------------------------------------------------------------------------------ Mailing Address (if different from Home Address) 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 on the first death of either Owner.) ------------------------------------------------------------------------------------------------------------------------------------ (FIRST) (MIDDLE) (LAST) ___ SSN ___ TIN (include dashes) ------------------------------------------------------------------------------------------------------------------------------------ Home Address (Physical Address Required) CITY STATE ZIP Relationship to Owner (Check One) ___ Spouse ___ Other _________________ ------------------------------------------------------------------------------------------------------------------------------------ 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) (FIRST) (MIDDLE) (LAST) ___ SSN ___ TIN (include dashes) ------------------------------------------------------------------------------------------------------------------------------------ Home Address (number and street) CITY STATE ZIP Relationship to Owner (Check One) ___ Spouse ___ Other _________________ ------------------------------------------------------------------------------------------------------------------------------------ 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 (if other than Joint Owner) (FIRST) (MIDDLE) (LAST) ___ SSN ___ TIN (include dashes) ------------------------------------------------------------------------------------------------------------------------------------ Home Address (number and street) CITY STATE ZIP Relationship to Owner (Check One) ___ Spouse ___ Other _________________ ------------------------------------------------------------------------------------------------------------------------------------ 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 (Check One) Date of Birth (mm/dd/yyyy) Address (number and street) City, State, ZIP ___ Spouse ___ Other _________________ ------------------------------------------------------------------------------------------------------------------------------------ __ 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 ------------------------------------------------------------------------------------------------------------------------------------ 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 220 05/07 FT4173 05/07 ------------------------------------------------------------------------------------------------------------------------------------ ANNUITY TYPE ------------------------------------------------------------------------------------------------------------------------------------ __ Non-Tax Qualified __ IRA - SEP __ IRA - Individual* __ 401(k) Qualified Savings Plan __ IRA - Custodial __ IRA - Roth* __ HR-10 (Keogh) Plan __ Other -________ *Tax Contribution Years and Amounts: __ 403(b) TSA (Direct Transfer Only) Year:______ $______ Year:______ $______ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ TRANSFER INFORMATION ------------------------------------------------------------------------------------------------------------------------------------ Transfer request submitted directly to another institution? __ Yes __ No __ IRC 1035 Exchange If yes, complete the following: __ Direct Transfer Anticipated Amount: $________________ __ Direct Rollover Anticipated Date of Receipt (mm/dd/yyyy): ________________ __ Non-Direct Rollover Institution releasing funds: _____________________________________ Account Number: __________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------- 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, the Company will default to the Latest Income Date as shown in the contract. ----------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------ 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. ___ Highest Anniversary Value Death Benefit 2. ___ Combination of 5% Roll-Up and Highest Anniversary Value Death Benefit (4% if the Owner is age 70 or older on the date of issue). 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 GUARANTEED LIVING BENEFIT OPTIONS (CONTINUED) __ EarningsMax(R) Guaranteed Minimum Withdrawal Benefits (GMWB) B. WITHDRAWAL OPTIONS __ SAFEGUARD 7 PLUS(SM) __ 20% Free Withdrawal Benefit (1) (7% GMWB with 5-Year Step-Up) __ 5-Year Withdrawal Charge Schedule __ AUTOGUARD 5(SM) (5% GMWB with Annual Step-Up) C. CONTRACT ENHANCEMENT OPTIONS __ AUTOGUARD 6(SM) (MAY SELECT ONLY ONE) (6% GMWB with Annual Step-Up) __ 2% of first-year premium __ LIFEGUARD ADVANTAGE(SM) __ 4% of first-year premium (5% For Life GMWB with Bonus and Annual Step-Up) __ 5% of first-year premium (2) __ LIFEGUARD ASCENT(SM) (For Life GMWB with Annual Step-Up) __ LIFEGUARD ASCENT WITH JOINT OPTION(SM) (4)(5) D. GUARANTEED LIVING BENEFIT OPTIONS (Joint For Life GMWB with Annual Step-Up) (MAY SELECT ONLY ONE GMAB OR GMWB) Guaranteed Minimum Accumulation Benefit (GMAB) __ GMAB (3) ADDITIONAL CHARGES WILL APPLY. PLEASE SEE THE PROSPECTUS FOR DETAILS. (1) May not be selected in combination with the 4% or 5% Contract Enhancements. (2) If selected, premium payments will not be accepted after the first Contract Year. (3) May not be selected in combination with a Contract Enhancement or with the Capital Protection Program. Premium payments will not be accepted after 90 days of the Issue Date. The required allocation percentage can be obtained from the Company. (4) For Non-Qualified plans, spousal joint ownership required. Please ensure the Joint Owner section on Page 1 (including the "Relationship to Owner" box) is properly completed. (5) For Qualified plans, 100% spousal primary beneficiary designation required. Please ensure the Primary Beneficiary section on Page 1 (including the "Relationship to Owner" box) is properly completed. ----------------------------------------------------------------------------------------------------------------------------- Page 2 of 6 VDA 220 05/07 FT4173 05/07 ------------------------------------------------------------------------------------------------------------------------------------ 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 222 ___% JNL/Mellon Capital Mgmt Nasdaq(R) 15 204 ___% Fifth Third Mid Cap VIP 244 ___% JNL/Mellon Capital Mgmt NYSE(R) International 25 202 ___% Fifth Third Quality Growth VIP 074 ___% JNL/Mellon Capital Mgmt S&P 24 203 ___% Fifth Third Balanced VIP 223 ___% JNL/Mellon Capital Mgmt Value Line(R) 25 196 ___% JNL(R)/AIM Large Cap Growth 248 ___% JNL/Mellon Capital Mgmt S&P SMid 60 206 ___% JNL/AIM Real Estate 096 ___% JNL/Mellon Capital Mgmt Dow Dividend 195 ___% JNL/AIM Small Cap Growth 225 ___% JNL/Mellon Capital Mgmt VIP 066 ___% JNL/Credit Suisse Global Natural Resources 191 ___% JNL/Mellon Capital Mgmt Communications 068 ___% JNL/Credit Suisse Long/Short 185 ___% JNL/Mellon Capital Mgmt Consumer Brands 115 ___% JNL/Eagle Core Equity 189 ___% JNL/Mellon Capital Mgmt Financial Sector 116 ___% JNL/Eagle SmallCap Equity 188 ___% JNL/Mellon Capital Mgmt Healthcare Sector 150 ___% JNL/FI Balanced 190 ___% JNL/Mellon Capital Mgmt Oil & Gas Sector 101 ___% JNL/FI Mid-Cap Equity 187 ___% JNL/Mellon Capital Mgmt Technology Sector 062 ___% JNL/Franklin Templeton Founding Strategy 054 ___% JNL/Mellon Capital Mgmt Enhanced S&P 500 Stock Index 069 ___% JNL/Franklin Templeton Global Growth 173 ___% JNL/Oppenheimer Global Growth 075 ___% JNL/Franklin Templeton Income 078 ___% JNL/PIMCO Real Return 064 ___% JNL/Franklin Templeton Mutual Shares 127 ___% JNL/PIMCO Total Return Bond 208 ___% JNL/Franklin Templeton Small Cap Value 136 ___% JNL/PPM America High Yield Bond 110 ___% JNL/Goldman Sachs Core Plus Bond 106 ___% JNL/PPM America Value Equity 207 ___% JNL/Goldman Sachs Mid Cap Value 105 ___% JNL/Putnam Equity 076 ___% JNL/Goldman Sachs Short Duration Bond 148 ___% JNL/Putnam Midcap Growth 113 ___% JNL/JPMorgan International Equity 104 ___% JNL/Select Balanced 126 ___% JNL/JPMorgan International Value 103 ___% JNL/Select Global Growth 109 ___% JNL/JPMorgan U.S. Government & Quality Bond 102 ___% JNL/Select Large Cap Growth 077 ___% JNL/Lazard Emerging Markets 107 ___% JNL/Select Money Market 132 ___% JNL/Lazard Mid Cap Value 179 ___% JNL/Select Value 131 ___% JNL/Lazard Small Cap Value 111 ___% JNL/T. Rowe Price Established Growth 123 ___% JNL/Mellon Capital Mgmt S&P 500(R) Index 112 ___% JNL/T. Rowe Price Mid-Cap Growth 124 ___% JNL/Mellon Capital Mgmt S&P(R) 400 MidCap Index 149 ___% JNL/T. Rowe Price Value 128 ___% JNL/Mellon Capital Mgmt Small Cap Index 129 ___% JNL/Mellon Capital Mgmt International Index THE FOLLOWING 5 OPTIONS ARE S&P PORTFOLIOS 133 ___% JNL/Mellon Capital Mgmt Bond Index 227 ___% JNL/S&P Managed Conservative 242 ___% JNL/Mellon Capital Mgmt Index 5 226 ___% JNL/S&P Managed Moderate 145 ___% JNL/Mellon Capital Mgmt Dow(SM) 10 117 ___% JNL/S&P Managed Moderate Growth 193 ___% JNL/Mellon Capital Mgmt S&P 10 118 ___% JNL/S&P Managed Growth 183 ___% JNL/Mellon Capital Mgmt Global 15 119 ___% JNL/S&P Managed Aggressive Growth 184 ___% JNL/Mellon Capital Mgmt 25 186 ___% JNL/Mellon Capital Mgmt Select Small-Cap FIXED ACCOUNT OPTIONS 224 ___% JNL/Mellon Capital Mgmt JNL 5 041 __% 1-year 243 ___% JNL/Mellon Capital Mgmt 10 x 10 043 __% 3-year 079 ___% JNL/Mellon Capital Mgmt JNL Optimized 5 045 __% 5-year 047 __% 7-year TO SELECT CAPITAL PROTECTION PROGRAM, AUTOMATIC REBALANCING OR DCA+, PLEASE SEE NEXT PAGE. ------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------- ALL PREMIUM ALLOCATION OPTIONS MAY NOT BE AVAILABLE IN ALL STATES. RESTRICTIONS MAY APPLY AT JACKSON'S DISCRETION ON A NON-DISCRIMINATORY BASIS. ----------------------------------------------------------------------------- Page 3 of 6 VDA 220 05/07 FT4173 05/07 ----------------------------------------------------------------------------------------------------------------------------- CAPITAL PROTECTION PROGRAM ----------------------------------------------------------------------------------------------------------------------------- __ Yes __ No (If no selection is made, Jackson(SM) 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 Having selected the Capital Protection Program, the balance of your initial premium will be allocated as indicated in the Premium Allocation Section on page 3. ----------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------ SYSTEMATIC INVESTMENT ------------------------------------------------------------------------------------------------------------------------------------ ___ CHECK HERE FOR AUTOMATIC REBALANCING. Only the DCA+ ($15,000 CONTRACT MINIMUM) Portfolios selected in the Premium Allocation Section and the 030 ____% 6-month 1-year Fixed Account (if selected) will participate in the 032 ____% 12-month program. The 3-, 5- and 7-year Fixed Accounts are not available for Automatic Rebalancing. IF DCA+ IS SELECTED, YOU MUST ATTACH THE SYSTEMATIC INVESTMENT FORM (V2375). Frequency: ___ Monthly ___ Quarterly ___ Semi-Annual ___ Annual DCA+ provides an automatic monthly transfer to the selected Portfolio(s) so the entire amount invested in this program, Start Date: ___________________________________________ plus earnings, will be transferred by the end of the DCA+ term selected. If no date is selected, the program will begin one month/quarter/half year/year (depending on the frequency you selected) from the date Jackson applies the first premium payment. If no frequency is selected, the frequency will be annual. ------------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------- TELEPHONE/ELECTRONIC TRANSFERS AUTHORIZATION -------------------------------------------------------------------------------- DO YOU WISH TO AUTHORIZE THESE TYPES OF TRANSFERS? ___ Yes ____ No By checking "Yes", I (We) authorize Jackson National Life Insurance Company (Jackson) to accept fund transfers/allocation changes via telephone, Internet, or other electronic medium from me (us) and my (our) Representative subject to Jackson's administrative procedures. Jackson has administrative procedures that are designed to provide reasonable assurances that telephone/electronic authorizations are genuine. If Jackson fails to employ such procedures, it may be held liable for losses resulting from a failure to use such procedures. I (We) agree that Jackson, 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, JACKSON WILL DEFAULT TO "NO" FOR RESIDENTS OF NORTH DAKOTA AND NEW HAMPSHIRE AND TO "YES" FOR RESIDENTS OF ALL OTHER STATES. -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- ELECTRONIC RECEIPT OF STATEMENTS/CORRESPONDENCE -------------------------------------------------------------------------------- I (We) consent ___ to electronic delivery of the following: ___ quarterly statements ___ prospectuses and prospectus supplements ___ periodic and immediate ___ proxy and other voting materials, related confirmations correspondence ___ annual and semi-annual ___ other documents from Jackson National Life reports Insurance Company. This consent will continue unless and until revoked and will cover delivery to you in the form of a compact disc, by e-mail or by notice to you of a document's availability on a web-site. I (We) do not consent ___ to electronic delivery for any of the documents listed above. The computer hardware and software requirements that are necessary to receive, process and retain electronic communications that are subject to this consent are as follows: To view and download material electronically, you must have a computer with Internet access, an active e-mail account, Adobe Acrobat Reader and/or a CD-ROM drive. If you don't already have Adobe Acrobat Reader, you can download it free from WWW.ADOBE.COM I (We) do __ do not ___ have ready access to computer hardware and software that meet the above requirements. My e-mail address is:__________________________. I (We) will notify the company of any new e-mail address. There is no charge for electronic delivery, although you may incur the costs of Internet access and of such computer and related hardware and software as may be necessary for you to receive, process and retain electronic documents and communications from Jackson. Please make certain you have given Jackson a current e-mail address. Also let Jackson know if that e-mail address changes. We may need to notify you of a document's availability through e-mail. You may request paper copies, whether or not you consent or revoke your consent for electronic delivery, at any time and for no charge. Please contact the appropriate Jackson Service Center or go to www.jnl.com to update your e-mail address, revoke your consent to electronic delivery, or request paper copies. Even if you have given us consent, we are not required to make electronic delivery and we have the right to deliver any document or communication in paper form. This consent will need to be supplemented by specific electronic consent upon receipt of any of these means of electronic delivery or notice of availability. -------------------------------------------------------------------------------- Page 4 of 6 VDA 220 05/07 FT4173 05/07 -------------------------------------------------------------------------------- IMPORTANT - PLEASE READ CAREFULLY - SIGNATURE(S) REQUIRED BELOW - THIS ENTIRE SECTION MUST BE COMPLETED FOR "GOOD ORDER" -------------------------------------------------------------------------------- STATEMENT REGARDING EXISTING POLICIES OR ANNUITY CONTRACTS I (We) certify that: ___ I (We) do not have any existing life insurance policies or annuity contracts. ___ I (We) do have existing life insurance policies or annuity contracts. PRODUCER: IF THE APPLICANT DOES HAVE EXISTING LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS YOU MUST PRESENT AND READ TO THE APPLICANT THE NOTICE REGARDING REPLACEMENT (X0512 - STATE VARIATIONS MAY APPLY) AND RETURN THE NOTICE, SIGNED BY BOTH THE PRODUCER AND THE APPLICANT, WITH THE APPLICATION. COMPLETE X0512 WHERE REQUIRED -------------------------------------------------------------------------------- REPLACEMENT ARE YOU REPLACING AN EXISTING LIFE INSURANCE POLICY OR ANNUITY CONTRACT? ___ YES ___ NO IF "YES", COMPLETE THE FOLLOWING. -------------------------------------------------------------------------------- Company Name Contract No. Anticipated Transfer Amount $ -------------------------------------------------------------------------------- Company Name Contract No. Anticipated Transfer Amount $ -------------------------------------------------------------------------------- 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, DEATH BENEFIT VALUES, AND WITHDRAWAL VALUES, IF ANY, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A PORTFOLIO IN THE SEPARATE ACCOUNT OF JACKSON 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 -------------------------------------------------------------------------------- Owner's Signature Date Signed (mm/dd/yyyy) State where signed -------------------------------------------------------------------------------- Owner Title (If owned by an entity) -------------------------------------------------------------------------------- Joint Owner Signature Date Signed (mm/dd/yyyy) State where signed -------------------------------------------------------------------------------- Annuitant's Signature (if other than Owner) -------------------------------------------------------------------------------- Joint Annuitant's Signature Date Signed (mm/dd/yyyy) State where signed (if other than Joint Owner) -------------------------------------------------------------------------------- PRODUCER/REPRESENTATIVE PLEASE COMPLETE AND SUBMIT PAGE 6 FOR GOOD ORDER Page 5 of 6 VDA 220 05/07 FT4173 05/07 -------------------------------------------------------------------------------- PRODUCER/REPRESENTATIVE'S STATEMENT - SIGNATURE(S) REQUIRED BELOW - THIS ENTIRE SECTION MUST BE COMPLETED FOR "GOOD ORDER" -------------------------------------------------------------------------------- PRODUCER/REPRESENTATIVE'S CERTIFICATION REGARDING SALES MATERIAL Important Note: Complete this certification section only if the applicant answered affirmatively to the Statement Regarding Existing Policies or Annuity Contracts AND answered "Yes" to EITHER question 1 or 2 on the Notice Regarding Replacement (Form X0512 - state variations may apply). I certify that: __ I did not use sales material(s) during the presentation of this Jackson product to the applicant. __ I used only Jackson-approved sales material(s) during the presentation of this Jackson product to the applicant. In addition, copies of all approved sales material(s) used during the presentation were left with the applicant. -------------------------------------------------------------------------------- PRODUCER/REPRESENTATIVE'S STATEMENT I have read Jackson's Position With Respect to the Acceptability of Replacements (XADV5790 - state variations may apply) and ensure that this replacement is consistent with that position. By signing this form, I certify that the statement regarding any applicable life insurance policies or annuity contracts and the statement regarding sales material have been answered correctly to the best of my knowledge. 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.
---------------------------------------------------------------------------------------------------------------- Producer/Representative's Full Name (First) (Middle) (Last) Phone No. (include area code) (please print) ---------------------------------------------------------------------------------------------------------------- Producer/Representative's Signature Date Signed (mm/dd/yyyy) ---------------------------------------------------------------------------------------------------------------- Address (number and street) City, State, ZIP (xxxxx-xxxx) ---------------------------------------------------------------------------------------------------------------- E-Mail Address Contact your home office for program information. (If none indicated, designated default will be used.) __ Option A __ Option B __ Option C __ Option D __ Option E ---------------------------------------------------------------------------------------------------------------- Broker/Dealer Name Broker/Dealer Representative No. Jackson 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.
----------------------------------------------------------------------------------- MAILING ADDRESS AND CONTACT INFORMATION ----------------------------------------------------------------------------------- REGULAR MAIL: Jackson/IMG Service Center, P.O. Box 30392, Lansing, MI 48909-7892 OVERNIGHT MAIL: Jackson/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 6 of 6 VDA 220 05/07 FT4173 05/07