EX-99 2 pii_application.txt EX-5v JACKSON(R) NATIONAL LIFE INSURANCE COMPANY Home Office: Lansing, Michigan www.jackson.com PERSPECTIVE II(R)(09/09) FIXED AND VARIABLE ANNUITY APPLICATION (VA220) -------------------------------------------------------------------------------- CUSTOMER CARE: 800/873-5654 BANK OR FINANCIAL INSTITUTION CUSTOMER CARE: 800/777-7779 HOURS: 8:00 a.m. to 8:00 p.m. ET FAX: 800/943-6761 E-MAIL: contactus@jackson.com FIRST CLASS MAIL: P.O. Box 30314 Lansing, MI 48909-7814 OVERNIGHT MAIL: 1 Corporate Way Lansing, MI 48951 -------------------------------------------------------------------------------- Broker/Dealer or External Account No. (if applicable)
------------------------------------------------------------------------------------------------------------------------------------ PLEASE PRINT - PRIMARY OWNER ------------------------------------------------------------------------------------------------------------------------------------ Social Security Number or Tax I.D. Number Sex: Male __ Female __ U.S. Citizen: Yes __ No __ ------------------------------------------------------------------------------------------------------------------------------------ First Name Middle Name Last Name ------------------------------------------------------------------------------------------------------------------------------------ Non-Natural Owner/Entity Name (If Owner is a Trust, Trustee Certification Form X5335 or trust documents are required with application.) ------------------------------------------------------------------------------------------------------------------------------------ Date of Birth (mm/dd/yyyy) Telephone Number (including area code) Email Address ------------------------------------------------------------------------------------------------------------------------------------ Physical Address Line 1 (No P.O. Boxes) (It is required for Good Order that you provide a physical address.) Line 2 ------------------------------------------------------------------------------------------------------------------------------------ City STATE ZIP ------------------------------------------------------------------------------------------------------------------------------------ Mailing Address Line 1 Line 2 ------------------------------------------------------------------------------------------------------------------------------------ City STATE ZIP ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ JOINT OWNER (Proceeds will be distributed in accordance with the Contract on the first death of either Owner.) ------------------------------------------------------------------------------------------------------------------------------------ First Name Middle Name Last Name ------------------------------------------------------------------------------------------------------------------------------------ Social Security Number Date of Birth(mm/dd/yyyy) Sex: Male __ Female __ U.S. Citizen: Yes __ No __ ------------------------------------------------------------------------------------------------------------------------------------ Email Address Relationship to Owner Telephone Number (including area code) __Spouse __Other ___________ ------------------------------------------------------------------------------------------------------------------------------------ Physical Address Line 1 (No P.O. Boxes) Line 2 ------------------------------------------------------------------------------------------------------------------------------------ City STATE ZIP ------------------------------------------------------------------------------------------------------------------------------------ VDA 220 09/09 Page 1 of 8 V4173 09/09 PRIMARY ANNUITANT - Complete this section if different from owner. ------------------------------------------------------------------------------------------------------------------------------------ __ Same as Owner Sex: Male __ Female __ U.S. Citizen: Yes __ No __ ------------------------------------------------------------------------------------------------------------------------------------ First Name Middle Name Last Name ------------------------------------------------------------------------------------------------------------------------------------ Social Security Number Date of Birth (mm/dd/yyyy) Telephone No. (including area code) Relationship to Owner __ Spouse __ Other ____________ ------------------------------------------------------------------------------------------------------------------------------------ Physical Address Line 1 (No P.O. Boxes) Line 2 ------------------------------------------------------------------------------------------------------------------------------------ City STATE ZIP ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ JOINT/CONTINGENT ANNUITANT - Complete this section if different from Joint owner. Contingent Annuitant must be Annuitant's spouse. Available only on a Qualified plan custodial account when electing a Joint GMWB. ------------------------------------------------------------------------------------------------------------------------------------ __ Joint Annuitant OR __ Contingent Annuitant Sex: Male __ Female __ U.S. Citizen: Yes __ No __ __ Same as Joint Owner ------------------------------------------------------------------------------------------------------------------------------------ First Name Middle Name Last Name ------------------------------------------------------------------------------------------------------------------------------------ Social Security Number Date of Birth (mm/dd/yyyy) Telephone No. (including area code) Relationship to Owner __ Spouse __ Other ____________ ------------------------------------------------------------------------------------------------------------------------------------ Physical Address Line 1 (No P.O. Boxes) Line 2 ------------------------------------------------------------------------------------------------------------------------------------ City STATE ZIP ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ BENEFICIARY(IES) - It is required for Good Order that the Death Benefit Percentage be whole numbers and must total 100% for each beneficiary type. ------------------------------------------------------------------------------------------------------------------------------------ __ Primary _____% Percentage of Death Benefit ------------------------------------------------------------------------------------------------------------------------------------ Individual Name (First, Middle, Last) or Non-Natural Entity Name ------------------------------------------------------------------------------------------------------------------------------------ Social Security Number Date of Birth (mm/dd/yyyy) Relationship to Owner __ Spouse __ Other ____________ ------------------------------------------------------------------------------------------------------------------------------------ __ Primary ___ Contingent _____% Percentage of Death Benefit ------------------------------------------------------------------------------------------------------------------------------------ Individual Name (First, Middle, Last) or Non-Natural Entity Name ------------------------------------------------------------------------------------------------------------------------------------ Social Security Number/Tax I.D. Number Date of Birth (mm/dd/yyyy) Relationship to Owner ------------------------------------------------------------------------------------------------------------------------------------ __ Primary ___ Contingent _____% Percentage of Death Benefit ------------------------------------------------------------------------------------------------------------------------------------ Individual Name (First, Middle, Last) or Non-Natural Entity Name ------------------------------------------------------------------------------------------------------------------------------------ Social Security Number/Tax I.D. Number Date of Birth (mm/dd/yyyy) Relationship to Owner ------------------------------------------------------------------------------------------------------------------------------------ For additional beneficiaries, please attach a separate sheet, signed and dated by the Owner, which includes names, percentages, and other required information. VDA 220 09/09 Page 2 of 8 V4173 09/09 ------------------------------------------------------------------------------------------------------------------------------------ PREMIUM PAYMENT - Make all checks payable to JACKSON NATIONAL LIFE INSURANCE COMPANY(R) ------------------------------------------------------------------------------------------------------------------------------------ Select method of payment ___ Check $_________________________________ ___ Wire $_____________________________________ ___ External Transfer $_____________________ ___ Internal Transfer $________________________ ------------------------------------------------------------------------------------------------------------------------------------ ANNUITY TYPE - Jackson(R) will issue Annuity Type per the bold headings. ------------------------------------------------------------------------------------------------------------------------------------ IRA: Qualified Plan: TSA Plan: __ IRA - Traditional* __ 401(k) Qualified Savings Plan __ 403(b) TSA __ Stretch IRA __ Cash Balance-Defined Benefit SEP/IRA (408k): Roth IRA: __ Cash Balance-Defined Contribution __ SARSEP __ Roth Conversion __ Governmental Deferred __ SEP __ Roth IRA* Compensation Plan ORP: *Tax Contribution Years and Amounts: __ HR-10 (Keogh) Plan __ ORP Year:______ $______ __ Money Purchase __ Texas ORP Year:______ $______ __ Non-Profit Deferred Charitable REmainder Trust: Non-Qualified Plan: Compensation Plan __ Charitable Remainder __ Deferred Compensation __ Profit Sharing Plan Annuity Trust __ Non-Tax Qualified __ Roth 401k __ Charitable Remainder __ Target Benefit Plan Unitrust ------------------------------------------------------------------------------------------------------------------------------------ STATEMENT REGARDING EXISTING POLICIES OR ANNUITY CONTRACTS - It is required for Good Order that this entire section be completed. COMPLETE X0512 "REPLACEMENT OF LIFE INSURANCE OR ANNUITIES" WHERE REQUIRED (must be dated on or before the Application Sign Date to be in Good Order). ------------------------------------------------------------------------------------------------------------------------------------ I (We) certify that: (please select one) __ I (We) do not have any existing life insurance policies or annuity contracts. __ I (We) do have existing life insurance policies or annuity contracts. NOTICE TO PRODUCER/REPRESENTATIVE: IF THE APPLICANT DOES HAVE EXISTING LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS YOU MUST PRESENT AND READ TO THE APPLICANT THE REPLACEMENT OF LIFE INSURANCE OR ANNUITIES FORM (X0512 - STATE VARIATIONS MAY APPLY) AND RETURN THE NOTICE, SIGNED BY BOTH THE PRODUCER/REPRESENTATIVE AND APPLICANT, WITH THE APPLICATION. ARE YOU REPLACING AN EXISTING LIFE INSURANCE POLICY OR ANNUITY CONTRACT? __ YES __ NO (IF YES, COMPLETE THE FOLLOWING COMPANY INFORMATION.) Company Name Contract Number Anticipated amount _____________________________ _____________________________________ $___________________________ _____________________________ _____________________________________ $___________________________ _____________________________ _____________________________________ $___________________________ ------------------------------------------------------------------------------------------------------------------------------------ TRANSFER INFORMATION - For transfers, it is required for Good Order that this entire section be completed. ------------------------------------------------------------------------------------------------------------------------------------ Non-Qualified Plan Types: __ IRC 1035 Exchange __ Non-1035 Exchange All Other Plan Types: __ Direct Transfer __ Direct Rollover __ Non-Direct Rollover Have you submitted a transfer request to the surrendering institution? __ Yes __ No By marking "Yes," Jackson will not request the funds. Transfer Anticipated date Anticipated Type Company releasing funds Account number of receipt transfer amount __ Full _______________________ ______________ ___________________ $_________________ __ Partial _______________________ ______________ ___________________ $_________________ __ Full _______________________ ______________ ___________________ $_________________ __ Partial _______________________ ______________ ___________________ $_________________ __ Full _______________________ ______________ ___________________ $_________________ __ Partial _______________________ ______________ ___________________ $_________________ ------------------------------------------------------------------------------------------------------------------------------------ ANNUITIZATION/INCOME DATE ------------------------------------------------------------------------------------------------------------------------------------ Specify Income Date (mm/dd/yyyy) If an Income Date is not specified, the Company will default ________________________________ to the Latest Income Date as shown in the Contract. ------------------------------------------------------------------------------------------------------------------------------------ VDA 220 09/09 Page 3 of 8 V4173 09/09 ------------------------------------------------------------------------------------------------------------------------------------ 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. ------------------------------------------------------------------------------------------------------------------------------------ Select only one of the following (Ages 0-79) May not be selected in combination with LifeGuard Freedom 6 DB. 5% Roll-Up Death Benefit (4% if the Owner is age 70 or older on the date of issue) __ With Highest Quarterly Anniversary Value Death Benefit __ Without Highest Quarterly Anniversary Value Death Benefit 6% Roll-Up Death Benefit (5% if the Owner is age 70 or older on the date of issue) __ With Highest Quarterly Anniversary Value Death Benefit __ Without Highest Quarterly Anniversary Value Death Benefit __ Highest Quarterly Anniversary Value Death Benefit ------------------------------------------------------------------------------------------------------------------------------------ OTHER OPTIONAL BENEFITS - All optional benefits may not be available in all states and once selected cannot be changed. OPTIONAL DEATH BENEFITS AND OTHER OPTIONAL BENEFITS: ADDITIONAL CHARGES WILL APPLY. PLEASE SEE THE PROSPECTUS FOR DETAILS. ------------------------------------------------------------------------------------------------------------------------------------ Age limitations apply based on the age of the Owner(s) or Covered Lives. Earnings Protection Benefit Withdrawal Options __ Earnings Max(R) (Ages 0-75) __ 20% Free Withdrawal Benefit (7) (Ages 0-90) __ 5-Year Withdrawal Charge Schedule (Ages 0-85) Guaranteed Living Benefit Options Contract Enhancement Options (May Select only one GMAB or GMWB) (May select only one) (Ages 0-87) GMAB (Guaranteed Minimum Accumulation Benefit) __ 2% of first-year premium __ Jackson GMAB(SM)(1)(2)(Ages 0-80) __ 3% of first-year premium GMWB (Guaranteed Minimum Withdrawal Benefits) __ 4% of first-year premium __ SafeGuard Max (SM)(Ages 0-85) GMWB with 5-Year Step-Up __ 5% of first-year premium(8) __ AutoGuard(R) 5(Ages 0-80) 5% GMWB with Annual Step-Up __ AutoGuard 6 (Ages 0-80) 6% GMWB with Annual Step-Up GMWB For Life (For Life Guaranteed Minimum Withdrawal Benefits) __ LifeGuard Freedom 6(SM)(Ages 45-80) For Life GMWB with Bonus & Annual Step-Up __ LifeGuard Freedom 6 DB(SM)(3)(Ages 45-75) For Life GMWB with Bonus, Annual Step-Up & Death Benefit __ LifeGuard Freedom 6 w/Joint Option (4)(5)(6)(Ages 45-80) Joint For LIfe GMWB with Bonus & Annual Step-Up __ LifeGuard Select(SM)(2)(Ages 55-80) For Life GMWB with Bonus, GWB Adjustment, & Annual Step-Up __ LifeGuard Select w/Joint Option(2)(4)(5)(6)(Ages 55-80) Joint for Life GMWB with Bonus, GWB Adjustment, & Annual Step-Up (1) 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 from the Issue Date. The required allocation percentage can be obtained from the Company. (2) The total number of allocations in the Premium Allocation section may not exceed 17. (3) May not be selected in combination with an Optional Death Benefit. (4) For Non-Qualified plans, spousal joint ownership required unless non-natural owner, then spousal joint annuitants required. Please ensure the Joint Owner section on Page 1 (including the "Relationship to Owner" box) is properly completed. (5) For Qualified plans, excluding custodial accounts, 100% spousal primary beneficiary designation is required. Please ensure the Primary Beneficiary section on Page 2 (including the "Relationship to Owner" box) is properly completed. (6) For Qualified plan custodial accounts, Annuitant's spouse must be designated as Contingent Annuitant. (7) May not be selected in combination with either the 3%, 4%, or 5% Contract Enhancements. (8) If selected, premium payments will not be accepted after the first contract Year. ------------------------------------------------------------------------------------------------------------------------------------ SYSTEMATIC INVESTMENT (PERIODIC PREMIUM REALLOCATION PROGRAMS) - Only the Investment Division(s) selected in the Premium Allocation section and the 1-Year Fixed Account (if selected) will participate in the rebalancing program. ------------------------------------------------------------------------------------------------------------------------------------ Automatic Rebalancing. The 3, 5 and 7-Year Fixed Account DCA+ ($15,000 contract minimum) Options are not available for Automatic Rebalancing. _____% 6-month _____% 12-month Frequency: If DCA+ is selected, you must attach the __ Monthly __ Quarterly __ Semiannually __ Annually Systematic Investment Form (V2375) Start Date (mm/dd/yyyy) ________________________________ DCA+ provides an automatic monthly transfer to Note: If no date is selected, the program will begin the selected Investment Division(s) so the entire one month/quarter/half year/year (depending on the amount invested in this program, plus earnings, will frequency you selected) from the date Jackson applies be transferred by the end of the DCA+ term the first premium payment. If no frequency is selected, the selected. If selected, the total number of elections in frequency will be annual. No transfers will be made on the Premium Allocation section may not exceed 17. days 29, 30 or 31, unless set up on annual frequency. VDA 220 09/09 Page 4 of 8 V4173 09/09 ------------------------------------------------------------------------------------------------------------------------------------ PREMIUM ALLOCATION - Tell us how you want your annuity premiums invested. TOTAL ALLOCATION MUST EQUAL 100%. Total number of allocation selections may not exceed 18. All premium allocation options may not be available in all states. Restrictions may apply at Jackson's discretion on a non-discriminatory basis. ------------------------------------------------------------------------------------------------------------------------------------ JNL(R) JNL/M&G JNL/PPM America ___% Institutional Alt 20 ___% Global Basics ___% High Yield Bond ___% Institutional Alt 35 ___% Global Leaders ___% Mid Cap Value ___% Institutional Alt 50 ___% Small Cap Value ___% Institutional Alt 65 JNL/MELLON CAPITAL MANAGEMENT ___% Value Equity ___% JNL 5 JNL/AIM ___% Dow(SM) 10 JNL/RED ROCKS ___% International Growth ___% S&P(R) 10 ___% Listed Private Equity ___% Large Cap Growth ___% Global 15 ___% Global Real Estate ___% 25 JNL/SELECT ___% Small Cap Growth ___% Select Small-Cap ___% Balanced ___% JNL Optimized 5 ___% Money Market JNL/CAPITAL GUARDIAN ___% VIP ___% Value ___% Global Balanced ___% Dow Dividend ___% Global Diversified ___% European 30 JNL/T. ROWE PRICE Research ___% Nasdaq(R) 25 ___% Established Growth ___% International Small Cap ___% NYSE(R) International 25 ___% Mid-Cap Growth ___% U.S. Growth Equity ___% Pacific Rim 30 ___% Short-Term Bond ___% S&P 24 ___% Value JNL/CREDIT SUISSE ___% S&P SMid 60 ___% Commodity Securities ___% Value Line(R) 30 JNL/S&P STRATEGIC ___% Long/Short ___% S&P 500(R) Index ___% S&P 4 ___% S&P 400 MidCap Index ___% Competitive Advantage JNL/EAGLE ___% Small Cap Index ___% Dividend Income & ___% Core Equity ___% International Index Growth ___% SmallCap Equity ___% Bond Index ___% Intrinsic Value ___% Index 5 ___% Total Yield JNL/FRANKLIN TEMPLETON ___% 10 X 10 ___% Founding Strategy ___% Communications Sector JNL/S&P MANAGED ___% Global Growth ___% Consumer Brands Sector ___% Conservative ___% Income ___% Financial Sector ___% Moderate ___% Mutual Shares ___% Healthcare Sector ___% Moderate Growth ___% Small Cap Value ___% Oil & Gas Sector ___% Growth ___% Technology Sector ___% Aggressive Growth JNL/GOLDMAN SACHS ___% Global Alpha ___% Core Plus Bond JNL/S&P DISCIPLINED ___% Emerging Markets Debt JNL/OPPENHEIMER ___% Moderate ___% Mid Cap Value ___% Global Growth ___% Moderate Growth ___% Growth JNL/IVY JNL/PAM ___% Asset Strategy ___% Asia ex-Japan FIXED ACCOUNT OPTIONS ___% China-India ___% 1-Year JNL/JPMORGAN ___% 3-Year ___% International Value JNL/PIMCO ___% 5-Year ___% MidCap Growth ___% Real Return ___% 7-Year ___% U.S. Government & ___% Total Return Bond Quality Bond JNL/LAZARD ___% Emerging Markets ___% Mid Cap Equity VDA 220 09/09 Page 5 of 8 V4173 09/09 ------------------------------------------------------------------------------------------------------------------------------------ CAPITAL PROTECTION PROGRAM ------------------------------------------------------------------------------------------------------------------------------------ __ Yes __ No (If no selection is made, Jackson 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 5. ------------------------------------------------------------------------------------------------------------------------------------ TELEPHONE AND ELECTRONIC TRANSFERS AUTHORIZATION ------------------------------------------------------------------------------------------------------------------------------------ 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) Producer/Representative subject to Jackson's administrative procedures. This authorization is not extended to Authorized Callers. DO YOU AUTHORIZE THESE TYPES OF TRANSFERS? __ Yes __ No 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, not withstanding subsequent allegations of error or mistake in connection with any such transaction instruction. If no such election is made, Jackson will default to "No" for residents of Nebraska and North Dakota and to "Yes" for residents of all other states. ------------------------------------------------------------------------------------------------------------------------------------ ELECTRONIC DELIVERY AUTHORIZATION - Check the boxes next to the types of documents you wish to receive electronically. If an email address is provided, but no document type is selected, the selection will default to "All Documents." ------------------------------------------------------------------------------------------------------------------------------------ I AGREE TO RECEIVE DOCUMENTS ELECTRONICALLY: __ All documents __ Quarterly statements __ Prospectuses and prospectus supplements __ Periodic and immediate confirmation statements __ Proxy and other voting materials __ Annual and Semi-Annual reports __ Other Contract-related correspondence This consent will continue unless and until revoked and will cover delivery to you in the form of a compact disc, by email or by notice to you of a document's availability on a website. Certain types of correspondence may continue to be delivered by the United States Postal Service for compliance reasons. Registration on Jackson's website (www.jackson.com) is required for electronic delivery of Contract-related correspondence. I (We) do __ do not __ have ready access to computer hardware and software that meet the requirements listed below. My email address is: ___________________________________________. I (We) will notify the company of any new email address. 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 email 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. Please see Page 7 for further information regarding Electronic Delivery. ------------------------------------------------------------------------------------------------------------------------------------ AUTHORIZED CALLERS - If you want to authorize an individual other than your Producer/Rep to receive Contract information via telephone, please list that individual's information here. ------------------------------------------------------------------------------------------------------------------------------------ First Name Middle Name Last Name ------------------------------------------------------------------------------------------------------------------------------------ Social Security/Tax I.D. Number Date of Birth (mm/dd/yyyy) ------------------------------------------------------------------------------------------------------------------------------------ First Name Middle Name Last Name ------------------------------------------------------------------------------------------------------------------------------------ Social Security/Tax I.D. Number Date of Birth (mm/dd/yyyy) ------------------------------------------------------------------------------------------------------------------------------------ VDA 220 09/09 Page 6 of 8 V4173 09/09 ------------------------------------------------------------------------------------------------------------------------------------ NOTICE TO APPLICANT ------------------------------------------------------------------------------------------------------------------------------------ ARKANSAS, COLORADO, KENTUCKY, LOUISIANA, policyholder or claimant for the purpose of defrauding, MAINE, NEW MEXICO, OHIO, PENNSYLVANIA, AND or attempting to defraud, the policyholder or claimant WEST VIRGINIA RESIDENTS, PLEASE NOTE: Any person with regard to a settlement or award payable from who knowingly, and with intent to defraud any insurance proceeds, shall be reported to the Colorado insurance company or other person, files an application Division of Insurance within the Department of for insurance or statement of claim containing any Regulatory Agencies. materially false information or conceals for the purpose DISTRICT OF COLUMBIA RESIDENTS, PLEASE NOTE: of misleading, information concerning any fact material WARNING: It is a crime to provide false or misleading thereto, commits a fraudulent insurance act, which is a information to an insurer for the purpose of defrauding crime and subjects such person to criminal and civil the insurer or any other person. Penalties include penalties. imprisonment and/or fines. In addition, an insurer may In COLORADO, any insurance company, or agent of an deny insurance benefits, if false information materially insurance company, who knowingly provides false, related to a claim was provided by the applicant. incomplete, or misleading facts or information to a ELECTRONIC DELIVERY INFORMATION: 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 email address. Also let Jackson know if that email address changes. We may need to notify you of a document's availability through email. 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.jackson.com to update your email 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. ------------------------------------------------------------------------------------------------------------------------------------ CLIENT ACKNOWLEDGEMENTS ------------------------------------------------------------------------------------------------------------------------------------ (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 THE CONTRACT I (WE) HAVE APPLIED FOR IS VARIABLE AND EMPLOYS THE USE OF A SEPARATE ACCOUNT. I (WE) ALSO UNDERSTAND THAT THE ANNUITY BENEFITS, DEATH BENEFIT VALUES, AND WITHDRAWAL VALUES, IF ANY, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A INVESTMENT DIVISION IN THE SEPARATE ACCOUNT OF JACKSON ARE VARIABLE AND MAY BE INCREASED OR DECREASED, AND THE DOLLAR AMOUNTS ARE NOT GUARANTEED BY JACKSON OR ANY OTHER INSURANCE COMPANY, THE UNITED STATES GOVERNMENT OR ANY STATE GOVERNMENT, THE FDIC, FEDERAL RESERVE BOARD OR ANY OTHER FEDERAL OR STATE AGENCY. I (WE) UNDERSTAND THAT, EXCEPT FOR FUNDS ALLOCATED TO THE CONTRACT'S FIXED ACCOUNT OPTION, I (WE) WILL BEAR ALL RISK UNDER THE CONTRACT. (4) I (We) have been given a current prospectus for this variable annuity and for each available Investment Division. (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. (8) I (We) certify that the age of the Owner and any Joint Owner, primary spousal Beneficiary, Annuitant, Joint Annuitant, or Contingent Annuitant, if applicable, stated in this application are true and correctly recorded for purposes of electing an Optional Death Benefit or Other Optional Benefits. Owner's Signature Date Signed (mm/dd/yyyy) State where signed ------------------------------------------------------------------------------------------------------------------------------------ Owner's Title (required if owned by an Entity) ------------------------------------------------------------------------------------------------------------------------------------ Joint Owner Signature Date Signed (mm/dd/yyyy) State where signed ------------------------------------------------------------------------------------------------------------------------------------ Annuitant's Signature (if other than Owner) Date Signed (mm/dd/yyyy) State where signed ------------------------------------------------------------------------------------------------------------------------------------ Joint Annuitant's Signature (if other than Joint Owner) Date Signed (mm/dd/yyyy) State where signed ------------------------------------------------------------------------------------------------------------------------------------ VDA 220 09/09 Page 7 of 8 V4173 09/09 ------------------------------------------------------------------------------------------------------------------------------------ PRODUCER/REPRESENTATIVE ACKNOWLEDGMENTS - Complete this certification regarding sales material section only if: Your client has other existing policies or annuity contracts AND Will be either terminating any of those existing policies or using the funds from existing policies to fund this new Contract. ------------------------------------------------------------------------------------------------------------------------------------ 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. ------------------------------------------------------------------------------------------------------------------------------------ By signing this form, I certify that: 1. I am authorized and qualified to discuss the Contract herein applied for. 2. I have fully explained the Contract to the client, including Contract restrictions and charges and I believe this transaction is suitable given the client's financial situation and needs. 3. The Producer/Representative's Certification Regarding Sales Material has been answered correctly. 4. I have read Jackson's Position With Respect to the Acceptability of Replacements (XADV5790) and ensure that this replacement (if applicable) is consistent with that position. 5. The applicant's Statement Regarding Existing Policies or Annuity Contracts has been answered correctly to the best of my knowledge and belief. 6. The applicant's statement as to whether or not an existing life insurance policy or annuity contract is being replaced is true and accurate to the best of my knowledge and belief. 7. I have complied with requirements for disclosures and/or replacements as necessary. ------------------------------------------------------------------------------------------------------------------------------------ PROGRAM OPTIONS NOTE: CONTACT YOUR HOME OFFICE FOR PROGRAM INFORMATION. IF NO OPTION IS INDICATED, THE DESIGNATED DEFAULT WILL BE USED. Jackson Prod./Rep. No. Producer/Representative Signature Date Signed (mm/dd/yyyy) ------------------------------------------------------------------------------------------------------------------------------------ First Name Middle Name Last Name ------------------------------------------------------------------------------------------------------------------------------------ Broker/Dealer Name Program Options __ A __ B __ C __ D __ E ------------------------------------------------------------------------------------------------------------------------------------ Address (number and street) City State Zip Code ------------------------------------------------------------------------------------------------------------------------------------ Email Address Business Telephone No. (including area code) Percentage % ------------------------------------------------------------------------------------------------------------------------------------ If more than one Producer/Representative is participating in a Program Option on this case, please provide all Producer/ Representative names, Jackson Producer/Representative numbers and percentages for each (totaling 100%). IT IS REQUIRED FOR GOOD ORDER THAT ALL PRODUCER/REP NUMBERS BE SUPPLIED. Producer/Representative Name Jackson Producer/Representative No. Percentage % ------------------------------------------------------------------------------------------------------------------------------------ Producer/Representative Name Jackson Producer/Representative No. Percentage % ------------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------- NOT FDIC/NCUA INSURED * NOT BANK/CU GUARANTEED * MAY LOSE VALUE NOT A DEPOSIT * NOT INSURED BY ANY FEDERAL AGENCY -------------------------------------------------------------------------------- VDA 220 09/09 Page 8 of 8 V4173 09/09