v4473.htm

PERSPECTIVE ADVISORS II
(05/10) FIXED AND VARIABLE

ANNUITY APPLICATION (VA410)

Home Office: Lansing, Michigan

www.jackson.com

First Class Mail: P.O. Box 30314

Customer Care: 800-873-5654

Lansing, MI 48909-7814

Bank or Financial Institution Customer Care: 800-777-7779

Fax: 800-943-6761

Overnight Mail:

1 Corporate Way

Hours: 8:00 a.m. to 8:00 p.m. ET

Lansing, MI 48951

Email: contactus@jackson.com

Broker/Dealer or External Account No. (if applicable)

PLEASE PRINT

Primary Owner

Social Security Number

Tax I.D. Number

Sex

Male

Female

U.S. Citizen

Yes

First Name

Middle Name

Last Name

If Owner is a

Non-Natural Owner/Entity Name (if applicable)

Trust, Trustee

Certification
form X5335 or

trust

Date of Birth

(mm/dd/yyyy)

Telephone Number(including area code)

Email Address

documents are

required with

(

)

application.

Physical Address Line 1 (No P.O. Boxes)

Line 2

It is required
for Good

Order that

City

State

ZIP Code

you provide a
physical

address.

Mailing Address Line 1

Line 2

Only include
mailing

address if
different

City

State

ZIP Code

from physical
address.

Joint Owner

First Name

Middle Name

Last Name

Proceeds will

be distributed

in accordance

Social Security Number

Date of Birth (mm/dd/yyyy)

Sex

U.S. Citizen

with the

Male Female

Yes

Contract on

the first death
of either

Email Address

Relationship to Owner

Telephone Number (including area code)

Owner.

Spouse

(

)

Other__________________

Physical Address Line 1 (No P.O. Boxes)

Line 2

City

State

ZIP Code

VDA 410 09/09

Page 1 of 8

V4473 05/10

LONG-TERM SMART

Primary Annuitant

Same as Owner

Sex Male

Female

U.S. Citizen Yes

Complete this

First Name

Middle Name

Last Name

section if

different from

Owner.

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 Code

Joint/Contingent Annuitant

Joint Annuitant OR

Contingent Annuitant

Sex Male

Female

U.S. Citizen Yes

Same as Joint Owner

Complete this

section if

First Name

Middle Name

Last Name

different from

Joint Owner.

Contingent

Social Security Number

Date of Birth (mm/dd/yyyy)

Telephone No. (including area code)

Relationship to Owner

Annuitant

Spouse

must be

(

)

Other__________________

Annuitant's

spouse.

Physical Address Line 1 (No P.O. Boxes)

Line 2

Available only
on a Qualified
plan custodial

City

State

ZIP Code

account when
electing a

Joint GMWB.

Beneficiary(ies)

It is required

Primary

Percentage of Death Benefit

for Good

Order that the

Individual Name (First, Middle, Last) or Non-Natural Entity Name

Death Benefit

Percentage be

whole

Social Security/Tax I.D. Number Date of Birth

(mm/dd/yyyy)

Relationship to Owner

numbers and

must total

Spouse

100% for each

Other__________________

beneficiary
type.

Primary

Contingent

Percentage of Death Benefit

Individual Name (First, Middle, Last) or Non-Natural Entity Name

For additional

Social Security/Tax I.D. Number Date of Birth

(mm/dd/yyyy)

Relationship to Owner

beneficiaries,
please attach

a separate
sheet, signed
and dated by

Primary

Contingent

Percentage of Death Benefit

the Owner,
which

Individual Name (First, Middle, Last) or Non-Natural Entity Name

includes

names,

percentages,

and other

Social Security/Tax I.D. Number Date of Birth

(mm/dd/yyyy)

Relationship to Owner

required

information.

VDA 410 09/09

Page 2 of 8

V4473 05/10

LONG-TERM SMART

Make all

Premium Payment

checks

Select method of payment

payable to

Jackson

Check

$___________________________

Wire

$___________________________

National Life

External Transfer

$___________________

Internal Transfer

$___________________

Insurance

Company .

Annuity Type

IRA:

Qualified Plan:

SEP/IRA

(408(k)):

Jackson will

issue Annuity

IRA - Traditional*

401(k) Qualified Savings Plan

SARSEP

Type per the

Stretch IRA

Cash Balance-Defined Benefit

SEP

bold

Roth IRA:

Cash Balance-Defined Contribution

ORP:

headings.

Roth Conversion

HR-10 (Keogh) Plan

ORP

Roth IRA*

Money Purchase

Texas ORP

*Tax Contribution Years and Amounts:

Profit Sharing Plan

Charitable Remainder Trust:

Year:________ $___________

Roth 401(k)

Charitable Remainder

Year:________ $___________

Target Benefit Plan

Annuity Trust

Charitable Remainder

Non-Qualified Plan:

TSA Plan:

Unitrust

Deferred Compensation

403(b) TSA

Non-Tax Qualified

It is required

Statement Regarding Existing Policies or Annuity Contracts

for Good Order

that this entire

(We) certify that:

(please select one)

section be

I(We) do not have any existing life insurance policies or annuity contracts.

completed.

COMPLETE

(We) do have existing life insurance policies or annuity contracts.

X0512

Notice to Producer/Representative: If the Applicant does have existing life insurance policies or annuity contracts you

"REPLACEMENT

must present and read to the Applicant the Replacement of Life Insurance or Annuities form (X0512 - state variations

OF LIFE

may apply) and return the notice, signed by both the Producer/Representative and Applicant, with the Application.

INSURANCE OR

ANNUITIES"

Yes No

If yes, complete the

following Company

Are you replacing an existing life insurance policy or annuity contract?
WHERE

information.

REQUIRED

(must be dated

Company name

Contract number

Anticipated amount

on or before

the Application

Sign Date to be
in Good

Order).

Transfer Information

For transfers,

Non-Qualified Plan Types:

IRC 1035 Exchange

Non-1035 Exchange

it is required

for Good

All Other Plan Types:

Direct Transfer

Direct Rollover

Non-Direct Rollover

Order that this

Yes No

entire section

By marking "Yes," Jackson will not

Have you submitted a transfer request to the surrendering institution?

request the funds.

be completed.

Transfer

Anticipated date

Anticipated

Type

Company releasing funds

Account number

of receipt

transfer amount

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 410 09/09

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V4473 05/10

LONG-TERM SMART

Optional Death Benefits All optional death benefits may not be available in all states and once selected cannot be changed.

If no Optional

Select only one of the following. May not be selected in combination with LifeGuard Freedom 6 DB.

(Ages 0-79)

Death Benefit

5% Roll-Up Death Benefit

(4% if the owner is age 70 or older on the date of issue)

is selected your

beneficiary(ies)

With Highest Quarterly Anniversary Value Death Benefit

will receive the

standard

Without Highest Quarterly Anniversary Value Death Benefit

death benefit.

6% Roll-Up Death Benefit

(5% if the Owner is age 70 or older on the date of issue)

Please see the

prospectus for

With Highest Quarterly Anniversary Value Death Benefit

details.

Without Highest Quarterly Anniversary Value Death Benefit

Optional

Highest Quarterly Anniversary Value Death Benefit

Death

Benefits and

Other

Other Optional Benefits All optional benefits may not be available in all states and once selected cannot be changed.

Optional

Benefits:

Age limitations apply based on the age of the Owner(s) or Covered Lives.

Additional

Guaranteed Living Benefit Options

Guaranteed Living Benefit Options (Cont.)

charges will

(May select only one GMWB)

apply. Please

GMWB

see the

(Guaranteed Minimum Withdrawal Benefits)

GMWB For Life

prospectus

(For Life Guaranteed Minimum Withdrawal Benefits)

for details.

SafeGuard Max

(Ages 0-85)

LifeGuard Freedom 6

(Ages 45-80)

GMWB with 5-Year Step-Up

For Life GMWB with Bonus & Annual Step-Up

AutoGuard

(Ages 0-80)

LifeGuard Freedom 6 DB

(Ages 45-75)

5% GMWB with Annual Step-Up

For Life GMWB with Bonus, Annual Step-Up, & Death Benefit

AutoGuard 6

(Ages 0-80)

2,3,4

LifeGuard Freedom 6 w/ Joint Option

(Ages 45-80)

6% GMWB with Annual Step-Up

Joint For Life GMWB with Bonus & Annual Step-Up

LifeGuard Freedom 6 Net

(Ages 45-80)

For Life GMWB with Bonus, Annual Step-Up,

Contract Enhancement Option

& Earnings-Sensitive Withdrawal Amount

2% of first-year premium

(Ages 0-87)

2,3,4

LifeGuard Freedom 6 Net w/ Joint Option(Ages 45-80) Joint
For Life GMWB with Bonus, Annual Step-Up,

& Earnings-Sensitive Withdrawal Amount

Earnings Protection Benefit

Jackson Select

(Ages 55-80)

EarningsMax

(Ages 0-75)

For Life GMWB with Bonus, GWB Adjustment,
Annual Step-Up, & Transfer of Assets

2,3,4,5

Jackson Select w/ Joint Option

(Ages 55-80)

Joint For Life GMWB with Bonus, GWB Adjustment,
Annual Step-Up, & Transfer of Assets

May not be selected in combination with an Optional Death Benefit.

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. 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. For Qualified plan custodial accounts, Annuitant's spouse must be designated as
Contingent Annuitant. The total number of allocations in the Premium Allocation section may not exceed 17.

Only the

Systematic Investment

(periodic premium reallocation program)

Investment

Division(s)

Automatic Rebalancing

selected in the

Premium

Frequency (for Rebalancing or Dollar-Cost Averaging only):

Allocation

Monthly

Quarterly

Semiannually

Annually

section will

participate in

Start Date (mm/dd/yyyy) ___________________________

the program.

The Fixed

Note: If no date is selected, the program will begin one month/quarter/half year/year (depending on the frequency

Account

you selected) from the date Jackson applies the first premium payment. If no frequency is selected, the frequency

Option is not

will be annual. No transfers will be made on days 29, 30 or 31, unless set up on annual frequency.

available for

Automatic
Rebalancing.

VDA 410 09/09

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V4473 05/10

LONG-TERM SMART

Premium Allocation

Tell us how you

JNL®

JNL/JPMorgan

JNL/PAM

want your

% Institutional Alt 20

% International Value

% Asia ex-Japan

annuity

% Institutional Alt 35

% MidCap Growth

% China-India

premiums

invested. TOTAL

% Institutional Alt 50

% U.S. Government &

ALLOCATION

Quality Bond

JNL/PIMCO

% Institutional Alt 65

MUST EQUAL

% Real Return

100%.

JNL/Lazard

% Total Return Bond

JNL/AIM

% Emerging Markets

% International Growth

JNL/PPM America

% Mid Cap Equity

% Large Cap Growth

Total number of

% High Yield Bond

allocation

% Global Real Estate

JNL/M&G

% Mid Cap Value

selections may

% Small Cap Growth

not exceed 18.

% Small Cap Value

% Global Basics

JNL/American Funds®

% Global Leaders

% Value Equity

All premium

Blue Chip Income

JNL/Red Rocks

allocation

and Growth

JNL/Mellon Capital Management

options may

% Listed Private Equity

not be available

% Global Bond

% JNL 5

in all states.

Global Small

% Dow

JNL/Select

Restrictions

% Balanced

Capitalization

% S&P 10

may apply at

Jackson's

% Growth-Income

% Global 15

% Money Market

discretion on a

% Value

% International

% 25

non-

discriminatory

% New World

% Select Small-Cap

JNL/T. Rowe Price

basis.

% JNL Optimized 5

% Established Growth

JNL/Capital Guardian

% VIP

% Mid-Cap Growth

% Global Balanced

% Dow Dividend

% Short-Term Bond

Global Diversified

% European 30

Research

% Value

% Nasdaq 25

% U.S. Growth Equity

JNL/S&P Strategic

% NYSE International 25

% S&P 4

JNL/Credit Suisse

% Pacific Rim 30

% Commodity Securities

% Competitive Advantage

% S&P 24

% Long/Short

% S&P SMid 60

% Dividend Income &

Growth

% Value Line

JNL/Eagle

% Intrinsic Value

% S&P 500 Index

% Core Equity

% Total Yield

% S&P 400 MidCap Index

% SmallCap Equity

JNL/S&P Managed

% Small Cap Index

% Conservative

JNL/Franklin Templeton

% International Index

% Moderate

% Founding Strategy

% Bond Index

% Moderate Growth

% Global Growth

% Index 5

% Income

% Growth

% 10 x 10

% Aggressive Growth

% International Small

% Communications Sector

Cap Growth

JNL/S&P Disciplined

% Consumer Brands Sector

% Mutual Shares

% Moderate

% Financial Sector

It is required for

% Small Cap Value

% Moderate Growth

Good Order

% Healthcare Sector

that you

% Growth

JNL/Goldman Sachs

% Oil & Gas Sector

provide

% Core Plus Bond

Directed

% Technology Sector

Fixed Account Option*

Transfer form

% Emerging Markets Debt

% Global Alpha

% Fixed Account Option

(V4490) if

% Mid Cap Value

selecting the

* If selecting the Fixed Account

Fixed Account

JNL/Ivy

JNL/Oppenheimer

Option, automatic transfer of funds

Option.

over a 6-month period is required.

% Asset Strategy

% Global Growth

VDA 410 09/09

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V4473 05/10

LONG-TERM SMART

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.

Yes

Do you authorize these types of transfers?

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 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

I agree to receive documents electronically:

Check the

ALL DOCUMENTS

boxes next to

Quarterly statements

Prospectuses and prospectus supplements

the types of
documents you

Periodic and immediate confirmation statements

Proxy and other voting materials

wish to receive

electronically.

Annual and Semi-Annual reports

Other Contract-related correspondence

If an email
address is

This consent will continue unless and until revoked and will cover delivery to you in the form of a

provided, but

compact disc, by email or by notice to you of a document's availability on a website. Certain types of

no document

type is

correspondence may continue to be delivered by the United States Postal Service for compliance

selected, the

reasons. Registration on Jackson's website (www.jackson.com) is required for electronic delivery of

selection will

Contract-related correspondence.

default to "All

Documents."

(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

First Name

Middle Name

Last Name

other than
your

Producer/Rep

Social Security/Tax I.D. Number

Date of Birth(mm/dd/yyyy)

to receive
Contract

information via

telephone,

First Name

Middle Name

Last Name

please list that

individual's

information

here.

Social Security/Tax I.D. Number

Date of Birth(mm/dd/yyyy)

VDA 410 09/09

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V4473 05/10

LONG-TERM SMART

Notice to Applicant

ARKANSAS, COLORADO, KENTUCKY, LOUISIANA,

insurance proceeds, shall be reported to the Colorado

MAINE, NEW MEXICO, OHIO, PENNSYLVANIA, AND

Division of Insurance within the Department of

WEST VIRGINIA RESIDENTS, PLEASE NOTE: Any person

Regulatory Agencies.

who knowingly, and with intent to defraud any

DISTRICT OF COLUMBIA RESIDENTS, PLEASE NOTE:

insurance company or other person, files an application

WARNING: It is a crime to provide false or misleading

for insurance or statement of claim containing any

information to an insurer for the purpose of defrauding

materially false information or conceals for the purpose

the insurer or any other person. Penalties include

of misleading, information concerning any fact material

imprisonment and/or fines. In addition, an insurer may

thereto, commits a fraudulent insurance act, which is a

deny insurance benefits, if false information materially

crime and subjects such person to criminal and civil

related to a claim was provided by the applicant.

penalties.

RHODE ISLAND RESIDENTS, PLEASE NOTE: Any person

In COLORADO, any insurance company, or agent of an

who knowingly presents a false or fraudulent claim for

insurance company, who knowingly provides false,

payment of a loss or benefit or knowingly presents false

incomplete, or misleading facts or information to a

information in an application for insurance is guilty of a

policyholder or claimant for the purpose of defrauding,

crime and may be subject to fines and confinement in

or attempting to defraud, the policyholder or claimant

prison.

with regard to a settlement or award payable from

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)
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 410 09/09

Page 7 of 8

V4473 05/10

LONG-TERM SMART

Producer/Representative Acknowledgements

Complete this

certification

I certify that:

regarding sales

I did not use sales material(s) during the presentation of this Jackson product to the applicant.

material

section only if:

I used only Jackson-approved sales material(s) during the presentation of this Jackson product to the applicant.

Your client

In addition, copies of all approved sales material(s) used during the presentation were left with the applicant.

has other
existing

By signing this form, I certify that:

policies or

1. I am authorized and qualified to discuss the Contract herein applied for.

annuity

2. I have fully explained the Contract to the client, including Contract restrictions and charges and I believe this

contracts

transaction is suitable given the client's financial situation and needs.

AND

3. The Producer/Representative's Certification Regarding Sales Material has been answered correctly.

Will be either

4. I have read Jackson's Position With Respect to the Acceptability of Replacements (XADV5790) and ensure that

terminating

this replacement (if applicable) is consistent with that position.

any of those

5. The applicant's Statement Regarding Existing Policies or Annuity Contracts has been answered correctly to the

existing

best of my knowledge and belief.

policies or

6. The applicant's statement as to whether or not an existing life insurance policy or annuity contract is being

using the funds

replaced is true and accurate to the best of my knowledge and belief.

from existing

policies to fund

7. I have complied with requirements for disclosures and/or replacements as necessary.

this new

Contract.

Jackson Prod./Rep. No.

Producer/Representative Signature

Date Signed (mm/dd/yyyy)

First Name

Middle Name

Last Name

Program

Broker/Dealer Name

Program Options

Options Note:

Contact your
home office for

program

Address

(number and street)

City

State ZIP Code

information. If
no option is
indicated, the

designated

Email Address

Business Telephone No. (including area code)

Percentage

default will be

(

)

used.

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/Representative Name

Jackson Producer/Representative No.

Percentage

Producer/Rep

numbers be

supplied.

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 410 09/09

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V4473 05/10