v4173.htm

PERSPECTIVE II

(05/10)
FIXED AND VARIABLE

ANNUITY APPLICATION (VA220)

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 from

City

State

ZIP Code

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 220 09/09

Page 1 of 8

V4173 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

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

For additional

beneficiaries,

please attach a
separate sheet,

signed and

Primary

Contingent

Percentage of Death Benefit

dated by 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 220 09/09

Page 2 of 8

V4173 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

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

Yes

If yes, complete the

ANNUITIES"

following Company

WHERE

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

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

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 220 09/09

Page 3 of 8

V4173 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

With Highest Quarterly Anniversary Value Death Benefit

your

beneficiary(ies)

Without Highest Quarterly Anniversary Value Death Benefit

will receive the

6% Roll-Up Death Benefit

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

standard

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

Guaranteed Living Benefit Options (Cont.)

Other

Optional

(May select only one GMWB or GMAB)

GMWB

(Guaranteed Minimum Withdrawal Benefits)

Benefits:

GMWB For Life

SafeGuard Max

(Ages 0-85)

Additional

(For Life Guaranteed Minimum Withdrawal Benefits)

GMWB with 5-Year Step-Up

charges will

apply. Please

LifeGuard Freedom 6

(Ages 45-80)

AutoGuard

(Ages 0-80)

see the

For Life GMWB with Bonus & Annual Step-Up

5% GMWB with Annual Step-Up

prospectus

(Ages 45-75)

LifeGuard Freedom 6 DB

AutoGuard 6

(Ages 0-80)

for details.

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

6% GMWB with Annual Step-Up

2,3,4

LifeGuard Freedom 6 w/ Joint Option

(Ages 45-80)

GMAB

(Guaranteed Minimum Accumulation Benefit)

Joint For Life GMWB with Bonus & Annual Step-Up

Jackson GMAB 6 (Ages 0-80)

LifeGuard Freedom 6 Net

(Ages 45-80)

Contract Enhancement Options

For Life GMWB with Bonus, Annual Step-Up,

& Earnings-Sensitive Withdrawal Amount

(May select only one)

(Ages 0-87)

2,3,4

LifeGuard Freedom 6 Net w/ Joint Option

(Ages 45-80)

5% of first-year premium

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

4% of first-year premium

& Earnings-Sensitive Withdrawal Amount

3% of first-year premium

Jackson Select

(Ages 55-80)

2% of first-year premium

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

Withdrawal Options

2,3,4,5

Jackson Select w/ Joint Option

(Ages 55-80)

20% Free Withdrawal Benefit

(Ages 0-90)

Joint For Life GMWB with Bonus, GWB Adjustment,

5-Year Withdrawal Charge Schedule

(Ages 0-85)

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. 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.

Only the

Systematic Investment

(periodic premium reallocation programs)

Investment

Division(s)

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

DCA+ ($15,000 contract minimum)

selected in the

Options are not available for Automatic Rebalancing.

_______ % 6-month

Premium

Frequency:

_______ % 12-month

Allocation

Monthly

Quarterly

Semiannually

Annually

If DCA+ is selected, you must allocate Target

section and the

Start Date (mm/dd/yyyy) ___________________________

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

1-Year Fixed

Account (if

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

DCA+ provides an automatic monthly transfer to the

selected) will

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

selected Investment Division(s) so the entire amount

participate in

frequency you selected) from the date Jackson applies

invested in this program, plus earnings, will be

the rebalancing

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

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

program.

frequency will be annual. No transfers will be made on

selected, the total number of elections in the Premium

days

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

Allocation section may not exceed 17.

VDA 220 09/09

Page 4 of 8

V4173 05/10

LONG-TERM SMART

Premium Allocation

JNL®

JNL/JPMorgan

JNL/PAM

Tell us how you

want your

% Institutional Alt 20

% International Value

% Asia ex-Japan

annuity

% Institutional Alt 35

% MidCap Growth

% China-India

premiums

invested.

% Institutional Alt 50

% U.S. Government &

Quality Bond

JNL/PIMCO

TOTAL

% Institutional Alt 65

ALLOCATION

% Real Return

JNL/Lazard

MUST EQUAL

% Total Return Bond

JNL/AIM

100%.

% Emerging Markets

% International Growth

JNL/PPM America

% Mid Cap Equity

% Large Cap Growth

% High Yield Bond

% Global Real Estate

Total number

% Mid Cap Value

JNL/M&G

of allocation

% Small Cap Growth

% Small Cap Value

% Global Basics

selections may

% Value Equity

not exceed 18.

JNL/American Funds®

% Global Leaders

Blue Chip Income

JNL/Red Rocks

and Growth

JNL/Mellon Capital Management

% Listed Private Equity

All premium

% Global Bond

% JNL 5

allocation

JNL/Select

Global Small

% Dow

options may

Capitalization

% Balanced

not be available

% S&P 10

in all states.

% Money Market

% Global 15
% Growth-Income

Restrictions

% Value

% International

% 25

may apply at

Jackson's

% New World

% Select Small-Cap

JNL/T. Rowe Price

discretion on a

% JNL Optimized 5

non-

% Established Growth

JNL/Capital Guardian

discriminatory

% VIP

% Mid-Cap Growth

basis.

% 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

% S&P 24

% Competitive Advantage

% 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

% Growth

% Income

% 10 x 10

% Aggressive Growth

% International Small

% Communications Sector

Cap Growth

JNL/S&P Disciplined

% Consumer Brands Sector

% Mutual Shares

% Moderate

% Financial Sector

% Small Cap Value

% Moderate Growth

% Healthcare Sector

% Growth

JNL/Goldman Sachs

% Oil & Gas Sector

% Core Plus Bond

Fixed Account Options

% Technology Sector

% Emerging Markets Debt

% 1-Year

% Global Alpha

% Mid Cap Value

% 3-Year

JNL/Ivy

JNL/Oppenheimer

% 5-Year

% Asset Strategy

% Global Growth

% 7-Year

VDA 220 09/09

Page 5 of 8

V4173 05/10

LONG-TERM SMART

Capital Protection Program

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

I agree to receive documents electronically:

Check the

ALL DOCUMENTS

boxes next to

Quarterly statements

Prospectuses and prospectus supplements

the types of
documents

Periodic and immediate confirmation statements

Proxy and other voting materials

you wish to

receive

Annual and Semi-Annual reports

Other Contract-related correspondence

electronically.

If an email

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

address is

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

provided, but

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

no document

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

type is

selected, the

(We) do

do not

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

selection will

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

default to "All

any new email address.

Documents."

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.

If you want to

Authorized Callers

authorize an

individual

First Name

Middle Name

Last Name

other than
your

Producer/Rep

to receive

Social Security/Tax I.D. Number

Date of Birth(mm/dd/yyyy)

Contract

information

via telephone,

please list that

First Name

Middle Name

Last Name

individual's

information

here.

Social Security/Tax I.D. Number

Date of Birth(mm/dd/yyyy)

VDA 220 09/09

Page 6 of 8

V4173 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)
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 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

VDA 220 09/09

Page 8 of 8

V4173 05/10