v3573.htm

FIXED AND VARIABLE

ANNUITY APPLICATION (05/10)

Home Office: Lansing, Michigan

Perspective II

(VA220)

Perspective L Series (VA210)

www.jackson.com

Perspective Advisors II

(VA410)

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

If Owner

Type of Ownership:

Individual/Joint

Trust

Custodian

Corporation/Pension Plan

(and/or Joint

Owner) is not a

Social Security Number

Tax I.D. Number

Sex

Male

Female

U.S. Citizen

and/or a U.S.

U.S. Citizen

Yes

Resident, Form

W-9 or Form

First Name

Middle Name

Last Name

W-8BEN (as

applicable) is

required with

Non-Natural Owner/Entity Name (if applicable)

application.

If Owner is a
Trust, Trustee

Certification

Date of Birth

(mm/dd/yyyy)

Telephone Number(including area code)

Email Address

form X5335 or

(

)

trust

documents are

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

Line 2

required with
application.

It is required

for Good

City

State

ZIP Code

Order that you
provide a
physical

Mailing Address Line 1

Line 2

address.

Only include
mailing

address if

City

State

ZIP Code

different from
physical

address.

Joint Owner

Proceeds will

First Name

Middle Name

Last Name

be distributed

in accordance

with the

Contract on

Social Security Number

Date of Birth (mm/dd/yyyy)

Sex

U.S. Citizen

the first death

Male Female

Yes

of either
Owner.

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 Code

VDA 123 10/09

Page 1 of 9

V3573 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

Complete this

Same as Joint Owner

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 for

Primary

Percentage of Death Benefit

Good Order

that the Death

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

Benefit

Percentage be

whole numbers

and must total

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

(mm/dd/yyyy)

Relationship to Owner

100% for each

Spouse

beneficiary

Other__________________

type.

Primary

Contingent

Percentage of Death Benefit

For additional

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

beneficiaries,

please attach a
separate sheet,

signed and

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

(mm/dd/yyyy)

Relationship to Owner

dated by the

Owner, which

includes names,

percentages,

and other

Primary

Contingent

Percentage of Death Benefit

required

information.

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

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

(mm/dd/yyyy)

Relationship to Owner

VDA 123 10/09

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V3573 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

IRA - Traditional*

401(k) Qualified Savings Plan

SARSEP

issue Annuity

Stretch IRA

Cash Balance-Defined Benefit

SEP

Type per the

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 for

Statement Regarding Existing Policies or Annuity Contracts

Good Order

that this entire

(We) certify that:

(please select one)

section be

(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

Yes

If yes, complete the

ANNUITIES"

following Company

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

information.

REQUIRED

Company name

Contract number

Anticipated amount

(must be dated

on or before the

Application Sign
Date to be in

Good Order).

Transfer Information

Non-Qualified Plan Types:

IRC 1035 Exchange

Non-1035 Exchange

For transfers,
it is required

All Other Plan Types:

Direct Transfer

Direct Rollover

Non-Direct Rollover

for Good

Order that this

Please check the appropriate box(es) under the "Transfer Type" and "Client Initiated" headings. If you have already,

entire section

or plan to submit a transfer request to the surrendering institution, please select "Yes" under "Client Initiated."

be completed.

Jackson will only request the funds if this section is left blank or checked "No."

Transfer

Client

Anticipated date

Anticipated

Type

Initiated

Company releasing funds

Account number

of receipt

transfer amount

Full

Yes

Partial

Full

Yes

Partial

Full

Yes

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 123 10/09

Page 3 of 9

V3573 05/10

LONG-TERM SMART

Annuity Product Selection

It is required

Perspective II Fixed and Variable Annuity(VA220)

for Good

Order that

Perspective L Series Fixed and Variable Annuity (VA210)

you select

one product.

Perspective Advisors II Fixed and Variable Annuity

(VA410)

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

If no Optional

May select only one of the following: May not be selected in combination with LifeGuard Freedom 6 DB. (Ages 0-79)

Death Benefit

is selected

5% Roll-Up Death Benefit

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

your

With Highest Quarterly Anniversary Value Death Benefit

beneficiary(ies)

Without Highest Quarterly Anniversary Value Death Benefit

will receive the

standard

6% Roll-Up Death Benefit

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

death benefit.

With Highest Quarterly Anniversary Value Death Benefit

Please see the

Without Highest Quarterly Anniversary Value Death Benefit

prospectus for

details.

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

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

Benefits and

Guaranteed Living Benefit Options

(Cont.)

Other

(May select only one GMWB or GMAB)

GMWB

(Guaranteed Minimum Withdrawal Benefits)

Optional

Benefits:

GMWB For Life

SafeGuard Max

(Ages 0-85) GMWB with 5-Year Step-Up

Additional

(For Life Guaranteed Minimum Withdrawal Benefits)

AutoGuard

(Ages 0-80)

5% GMWB with Annual Step-Up

charges will

LifeGuard Freedom 6

(Ages 45-80)

apply. Please

AutoGuard 6

(Ages 0-80)

6% GMWB with Annual Step-Up

see the

For Life GMWB with Bonus & Annual Step-Up

prospectus

GMAB

(Guaranteed Minimum Accumulation Benefit)

LifeGuard Freedom 6 DB

(Ages 45-75)

for details.

(GMAB not available on Advisors II)

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

Jackson GMAB 6 (Ages 0-80)

2,3,4

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

Contract Enhancement Options

LifeGuard Freedom 6 Net

(Ages 45-80)

(May select only one)

(Ages 0-87)

For Life GMWB with Bonus, Annual Step-Up,

5% of first-year premium

(Not available on Advisors II)

& Earnings-Sensitive Withdrawal Amount

4% of first-year premium

(Not available on Advisors II)

2,3,4

LifeGuard Freedom 6 Net w/ Joint Option

(Ages 45-80)

3% of first-year premium

(Not available on Advisors II)

Joint For Life GMWB with Bonus, Annual Step-Up,

2% of first-year premium

& Earnings-Sensitive Withdrawal Amount

Jackson Select

(Ages 55-80)

Withdrawal Options

For Life GMWB with Bonus, GWB Adjustment,

(Withdrawal Options not available on Advisors II or L Series)

Annual Step-Up, & Transfer of Assets

20% Free Withdrawal Benefit

(Ages 0-90)

2,3,4,5

Jackson Select w/ Joint Option

(Ages 55-80)

5-Year Withdrawal Charge Schedule

(Ages 0-85)

Joint For Life GMWB with Bonus, GWB Adjustment,

Annual Step-Up, & Transfer of Assets

Earnings Protection Benefit

EarningsMax

(Ages 0-75)

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. If selected, the 3, 5, and 7-Year Fixed Account Options and the Capital Protection Program are not available. The total number of
allocations in the Premium Allocation section may not exceed 17.

May not be selected in combination with a Contract Enhancement or with the Capital Protection Program, if available. Premium payments will
not be accepted after 90 days from the Issue Date. The required allocation percentage can be obtained from the Company. The total number
of allocations in the Premium Allocation section may not exceed 17. May not be selected in combination with either the 3%, 4% or 5% Contract
Enhancements.

VDA 123 10/09

Page 4 of 9

V3573 05/10

LONG-TERM SMART

Premium Allocation

JNL®

JNL/Lazard

JNL/PPM America

Tell us how you

% Institutional Alt 20

% Emerging Markets

% High Yield Bond

want your

annuity

% Institutional Alt 35

% Mid Cap Equity

% Mid Cap Value

premiums

% Institutional Alt 50

% Small Cap Value

invested.

JNL/M&G

% Institutional Alt 65

TOTAL

% Global Basics

% Value Equity

ALLOCATION

JNL/AIM

% Global Leaders

MUST EQUAL

JNL/Red Rocks

% International Growth

100%.

JNL/Mellon Capital Management

% Listed Private Equity

% Large Cap Growth

% JNL 5

% Global Real Estate

JNL/Select

% Dow

Total number

% Small Cap Growth

% Balanced

% S&P 10

of allocation

JNL/American Funds®

% Money Market

selections may

% Global 15

Blue Chip Income

% Value

not exceed 18.

% 25

and Growth

% Select Small-Cap

JNL/T. Rowe Price

% Global Bond

% JNL Optimized 5

% Established Growth

All premium

Global Small

% VIP

% Mid-Cap Growth

allocation

Capitalization

options may

% Dow Dividend

% Short-Term Bond

% Growth-Income

not be available

% European 30

% Value

in all states.

% International

Restrictions

% Nasdaq 25

% New World

JNL/S&P Strategic

may apply at

% NYSE International 25

Jackson's

JNL/Capital Guardian

% S&P 4

discretion on a

% Pacific Rim 30

% Global Balanced

% Competitive Advantage

non-

% S&P 24

discriminatory

Global Diversified

% Dividend Income &

basis.

Research

% S&P SMid 60

Growth

% U.S. Growth Equity

% Intrinsic Value

% Value Line

JNL/Credit Suisse

% Total Yield

% S&P 500 Index

% Commodity Securities

% S&P 400 MidCap Index

JNL/S&P Managed

% Long/Short

% Small Cap Index

% Conservative

JNL/Eagle

% International Index

% Moderate

% Core Equity

% Bond Index

% Moderate Growth

% SmallCap Equity

% Index 5

% Growth

JNL/Franklin Templeton

% Aggressive Growth

% 10 x 10

% Founding Strategy

% Communications Sector

JNL/S&P Disciplined

% Global Growth

% Consumer Brands Sector

% Moderate

% Income

% Financial Sector

% Moderate Growth

% International Small

% Healthcare Sector

% Growth

Cap Growth

% Mutual Shares

% Oil & Gas Sector

Fixed Account Options*

% Small Cap Value

% Technology Sector

* (Not available on Advisors II)

For Advisors II

JNL/Goldman Sachs

% Global Alpha

% 1-Year

ONLY: It is

% Core Plus Bond

required for

% 3-Year

JNL/Oppenheimer

Good Order

% Emerging Markets Debt

% 5-Year

that you

% Global Growth

% Mid Cap Value

provide

% 7-Year

Directed

JNL/Ivy

JNL/PAM

Transfer form

% Asset Strategy

Fixed Account Option**

% Asia ex-Japan

(V4490) if

selecting the

JNL/JPMorgan

% China-India

(Advisors II ONLY)

Fixed Account

% International Value

** If selecting the Fixed Account

Option.

JNL/PIMCO

Option, automatic transfer of funds

% MidCap Growth

% Real Return

over a 6-month period is required.

% U.S. Government &

Quality Bond

% Total Return Bond

% Fixed Account Option

VDA 123 10/09

Page 5 of 9

V3573 05/10

LONG-TERM SMART

Systematic Investment

(periodic premium reallocation programs)

For all

Contracts

Automatic Rebalancing. The 3, 5 and 7-Year Fixed Account

DCA+ ($15,000 contract minimum)

except

Options are not available for Automatic Rebalancing.

_______ % 6-month

Advisors II:

Frequency:

Only the

_______ % 12-month

Monthly

Quarterly

Semiannually

Annually

Investment

If DCA+ is selected, you must allocate Target

Start Date (mm/dd/yyyy) ___________________________

Division(s)

Fund(s) using Systematic Investment Form (V2375).

selected in the

Note: If no date is selected, the program will begin

Premium

DCA+ provides an automatic monthly transfer to the

one month/quarter/half year/year (depending on the

Allocation

selected Investment Division(s) so the entire amount

frequency you selected) from the date Jackson applies

section and the

invested in this program, plus earnings, will be

the first premium payment. If no frequency is selected, the

1-Year Fixed

transferred by the end of the DCA+ term selected. If

frequency will be annual. No transfers will be made on

Account (if

selected, the total number of elections in the Premium

selected) will

days

29, 30 or 31, unless set up on annual frequency.

Allocation section may not exceed 17.

participate in

the rebalancing

For Advisors II: DCA+ is not available. Only the Investment Division(s) selected in the Premium Allocation section

program.

will participate in the rebalancing program. The Fixed Account Option is not available for Automatic Rebalancing.

Capital Protection Program

(Not

available on Advisors II)

Yes

(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.

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

Check the

I agree to receive documents electronically:

boxes next to

the types of

ALL DOCUMENTS

documents

Prospectuses and prospectus supplements

Quarterly statements

you wish to

receive

Periodic and immediate confirmation statements

Proxy and other voting materials

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 compact disc, by

provided, but

email or by notice to you of a document's availability on a website. Certain types of correspondence may continue

no document

to be delivered by the United States Postal Service for compliance reasons. Registration on Jackson's website

type is

(www.jackson.com) is required for electronic delivery of Contract-related correspondence.

selected, the

selection will

(We) do

do not

have ready access to computer hardware and software that meet the requirements

default to "All

listed below. My email address is:_________________________________________. I (We) will notify the company of

Documents."

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.

VDA 123 10/09

Page 6 of 9

V3573 05/10

LONG-TERM SMART

Authorized Callers

If you want to

First Name

Middle Name

Last Name

authorize an
individual
other than

your

Social Security/Tax I.D. Number

Date of Birth(mm/dd/yyyy)

Producer/Rep

to receive
Contract

First Name

Middle Name

Last Name

information via
telephone,
please list that

individual's

Social Security/Tax I.D. Number

Date of Birth(mm/dd/yyyy)

information

here.

Notice to Applicant

ARKANSAS, COLORADO, KENTUCKY, LOUISIANA,

regard to a settlement or award payable from insurance

MAINE, NEW MEXICO, OHIO, PENNSYLVANIA, AND

proceeds, shall be reported to the Colorado Division of

WEST VIRGINIA RESIDENTS, PLEASE NOTE: Any person

Insurance within the Department of Regulatory Agencies.

who knowingly, and with intent to defraud any

DISTRICT OF COLUMBIA RESIDENTS, PLEASE NOTE:

insurance company or other person, files an

WARNING: It is a crime to provide false or misleading

application for insurance or statement of claim

information to an insurer for the purpose of defrauding

containing any materially false information or

the insurer or any other person. Penalties include

conceals for the purpose of misleading, information

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

concerning any fact material thereto, commits a

deny insurance benefits, if false information materially

fraudulent insurance act, which is a crime and

related to a claim was provided by the applicant.

subjects such person to criminal and civil 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, or

crime and may be subject to fines and confinement in

attempting to defraud, the policyholder or claimant with

prison.

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.

VDA 123 10/09

Page 7 of 9

V3573 05/10

LONG-TERM SMART

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. (Not applicable to
Perspective Advisors II.)

8. I (We) certify that the age(s) of the Owner and any Joint Owner, primary spousal Beneficiary, Annuitant, Joint
Annuitant, or Contingent Annuitant, if applicable, stated in this application is (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

It is required for
Good Order

that all

applicable

Owner's Title (required if owned by an Entity)

parties to the

Contract sign

here.

Joint Owner's 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 123 10/09

Page 8 of 9

V3573 05/10

LONG-TERM SMART

Producer/Representative Acknowledgements

Complete this

certification

I certify that:

regarding

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

sales 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

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

funds from

existing

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

policies to

fund this new

Contract.

Jackson Prod./Rep. No.

Producer/Representative Signature

Date Signed (mm/dd/yyyy)

First Name

Middle Name

Last Name

Broker/Dealer Name

Program Options

Program

A B

D E

Options Note:

Contact your

home office

Address

(number and street)

City

State ZIP Code

for program
information. If
no option is

indicated, the

Email Address

Business Telephone No. (including area code)

Percentage

designated

(

)

default will be

used.

It is required

If more than one Producer/Representative is participating in a Program Option on this case, please provide all

for Good

Producer/Representative names, Jackson Producer/Representative numbers and percentages for each (totaling 100%).

Order that all
Producer/Rep

numbers be

Producer/Representative Name

Jackson Producer/Representative No.

Percentage

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

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