v3573.htm

Ex-5n

VARIABLE AND FIXED

ANNUITY APPLICATION (10/10)

Perspective II

(VA620)

Perspective L Series (VA610)

Home Office: Lansing, Michigan

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

First Name

Middle Name

Last Name

W-9 or Form
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 10/10

Page 1 of 9

V3573 10/10

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 10/10

Page 2 of 9

V3573 10/10

LONG-TERM SMART

Make all

Premium Payment

checks

Select method of payment

payable to

Jackson

Check

$___________________________

Wire

$___________________________

National Life

Insurance

External Transfer

$___________________

Internal Transfer

$___________________

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

Statement Regarding Existing Policies or Annuity Contracts

I (We) certify that:(please select one) It
is required for

Good Order

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

that this entire

section be

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

completed.

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

COMPLETE

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

X0512

" REPLACEMENT

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

OF LIFE

Yes

If yes, complete the

following Company

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

information.

ANNUITIES"

Company name

Contract number

Anticipated amount

WHERE

REQUIRED

(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

entire section

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

be completed.

Initiated." 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 10/10

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V3573 10/10

LONG-TERM SMART

Annuity Product Selection

It is required

Perspective II Fixed and Variable Annuity(VA620)

for Good

Perspective L Series Fixed and Variable Annuity (VA610)

Order that

you select

Perspective Advisors II Fixed and Variable Annuity(VA410)

one product.

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

May select only one of the following: May not be selected in combination with LifeGuard Freedom Flex DB.

If no Optional

Death Benefit

5% Roll-Up Death Benefit

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

(Ages 0-79)

is selected

With Highest Quarterly Anniversary Value Death Benefit

your

Without Highest Quarterly Anniversary Value Death Benefit

beneficiary(ies)

will receive the

6% Roll-Up Death Benefit

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

(Ages 0-79)

standard

With Highest Quarterly Anniversary Value Death Benefit

death benefit.

Without Highest Quarterly Anniversary Value Death Benefit

Please see the

prospectus for

Highest Quarterly Anniversary Value Death Benefit

(Ages 0-79)

details.

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

Optional

Guaranteed Living Benefit Options

(May select only one GMWB or GMAB)

Death

Benefits and

GMWB For Life

LifeGuard Freedom 6 Net

Other

(For Life Guaranteed Minimum Withdrawal Benefits)

For Life GMWB with Bonus, Annual Step-Up,

Optional

LifeGuard Freedom Flex

& Earnings-Sensitive Withdrawal Amount

(Ages 45-80)

Benefits:

For Life GMWB with Owner's choice of

1,2,3

Additional

LifeGuard Freedom 6 Net w/ Joint Option

Bonus and Step-Up

(Ages 35-80)

charges will

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

apply. Please

Bonus

Step-Up

& Earnings-Sensitive Withdrawal Amount

(Ages 45-80)

see the

(Must select one)

prospectus

Jackson Select

Annual

for details.

For Life GMWB with Bonus, GWB Adjustment,

Annual to Highest

Annual Step-Up, & Transfer of Assets

(Ages 55-80)

Quarterly Contract Value*

Election Age

1,2,3,5

* Not available with 8% bonus

Jackson Select w/ Joint Option

limitations

apply based

Joint For Life GMWB with Bonus, GWB Adjustment,

1,2,3

on the age of

LifeGuard Freedom Flex w/ Joint Option

Annual Step-Up, & Transfer of Assets

(Ages 55-80)

the Owner(s)

Joint For Life GMWB with Owner's choice of

or Covered

Bonus and Step-Up

(Ages 35-80)

GMWB

(Guaranteed Minimum Withdrawal Benefits)

Lives.

Bonus

Step-Up

SafeGuard Max

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

(Must select one)

AutoGuard

(Ages 0-80)

5% GMWB with Annual Step-Up

Annual

Annual to Highest

AutoGuard 6

(Ages 0-80)

6% GMWB with Annual Step-Up

Quarterly Contract Value*

*Not available with 7% bonus

GMAB

(Guaranteed Minimum Accumulation Benefit)

LifeGuard Freedom Flex DB

(Not available on Advisors II)

For Life GMWB with 6% Bonus, Annual Step-Up,

Jackson GMAB 6 (Ages 0-80)

and Death Benefit

(Ages 35-70)

Contract Enhancement Options

Withdrawal Options

(Not available on Advisors II or L Series)

(May select only one)

(Ages 0-87)

20% Free Withdrawal Benefit

(Ages 0-90)

5% of first year premium

(Not available on Advisors II)

5-Year Withdrawal Charge Schedule

(Ages 0-85)

4% of first year premium

(Not available on Advisors II)

3% of first year premium

(Not available on Advisors II)

Earnings Protection Benefit

2% of first year premium

EarningsMax

(Ages 0-75)

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

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 10/10

Page 4 of 9

V3573 10/10

LONG-TERM SMART

Premium Allocation

JNL®

JNL/JPMorgan

JNL/PAM

Tell us how you

% Institutional Alt 20

% International Value

% Asia ex-Japan

want your

annuity

% Institutional Alt 35

% MidCap Growth

% China-India

premiums

% Institutional Alt 50

% U.S. Government &

invested.

Quality Bond

TOTAL

% Institutional Alt 65

JNL/PIMCO

ALLOCATION

% Real Return

JNL/American Funds®

JNL/Lazard

MUST EQUAL

% Total Return Bond

100%.

Blue Chip Income

% Emerging Markets

and Growth

% Mid Cap Equity

% Global Bond

JNL/PPM America

JNL/M&G

Total number

Global Small

% High Yield Bond

of allocation

Capitalization

% Global Basics

% Mid Cap Value

selections may

% Global Leaders

% Growth-Income

% Small Cap Value

not exceed 18.

% International

% Value Equity

JNL/Mellon Capital Management

% New World

% JNL 5

All premium

JNL/Red Rocks

% Dow

JNL/BlackRock

allocation

% S&P 10

% Listed Private Equity

options may

% Commodity Securities

not be available

% Global 15

% Global Allocation

in all states.

% 25

JNL/Select

Restrictions

JNL/Capital Guardian

may apply at

% Select Small-Cap

% Balanced

Jackson's

% Global Balanced

% JNL Optimized 5

% Money Market

discretion on a

Global Diversified

% VIP

% Value

Researc
h non-

discriminatory

% U.S. Growth Equity

% Dow Dividend

basis.

% European 30

JNL/T. Rowe Price

JNL/Eagle

% Nasdaq

% Established Growth

% Core Equity

% NYSE International 25

% Mid-Cap Growth

% SmallCap Equity

% Pacific Rim 30

% Short-Term Bond

JNL/Franklin Templeton

% Value

% S&P 24

% Founding Strategy

% S&P SMid 60

% Global Growth

JNL/S&P

% Value Line

% Income

% 4

% S&P 500 Index

% Competitive Advantage

% International Small

% S&P 400 MidCap Index

Cap Growth

% Dividend Income &

% Small Cap Index

% Mutual Shares

Growth

% Small Cap Value

% International Index

% Intrinsic Value

% Bond Index

% Total Yield

JNL/Goldman Sachs

% Index 5

% Core Plus Bond

% 10 x 10

JNL/S&P Managed

% Emerging Markets Debt

% Communications Sector

% Conservative

% Mid Cap Value

% Consumer Brands Sector

% Moderate

% U.S. Equity Flex

% Moderate Growth

% Financial Sector

JNL/Invesco

% Healthcare Sector

% Growth

% Global Real Estate

% Aggressive Growth

% Oil & Gas Sector

% International Growth

% Technology Sector

% Large Cap Growth

JNL/S&P Disciplined

% Global Alpha

% Small Cap Growth

% Moderate

JNL/Ivy

JNL/Oppenheimer

% Moderate Growth

% Asset Strategy

% Global Growth

% Growth

PREMIUM ALLOCATIONS CONTINUED ON PAGE 6.

VDA 123 10/10

Page 5 of 9

V3573 10/10

LONG-TERM SMART

Premium Allocation

(Cont. from page 5)

For Advisors II

ONLY: It is

Fixed Account Option*

Fixed Account Options**

required for

** (Not available on Advisors II)

(Advisors II ONLY)

Good Order

that you

* If selecting the Fixed Account Option,

% 1-Year

provide

automatic transfer of funds over a

% 3-Year

Directed

6-month period is required.

Transfer form

% 5-Year

% Fixed Account Option

(V4490) if

% 7-Year

selecting the

Fixed Account

See the NOTE for some important

Option.

terms regarding the Fixed Account

Options.

For all Contracts except Advisors II, NOTE: The Contract permits Jackson without advance notice to restrict the amount of
Premium payments into, and the amount and frequency of transfers between, into and from, any Fixed Account; to close any Fixed
Account Option; and to require transfers from a Fixed Account Option. Accordingly, you should consider whether investment in a
Fixed Account Option is suitable given your investment objectives.

Systematic Investment(periodic premium reallocation programs)

For all

Contracts

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

DCA+ ($15,000 contract minimum)

except

Account Options are not available for Automatic

Advisors II:

_______ % 6-month

Rebalancing.

Only the

_______ % 12-month

Investment

Frequency:

Division(s) and

Monthly

Quarterly

Semiannually

Annually

If DCA+ is selected, you must allocate Designated

the 1-Year Fixed

Option(s) using Systematic Investment Form

Start Date (mm/dd/yyyy) ___________________________

Account Option

(V2375).

(subject to

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

availability) as

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

DCA+ provides an automatic monthly transfer to the

selected Investment Division(s) so the entire amount

selected in the

frequency you selected) from the date Jackson applies

Premium

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

invested in this program, plus earnings, will be

Allocation

frequency will be annual. No transfers will be made on

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

section will

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

selected, the total number of elections in the Premium

participate in

Allocation section may not exceed 17.

Automatic

Rebalancing.

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

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 and 6.

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, New Hampshire and North Dakota and to "
Yes" for residents of all other states.

VDA 123 10/10

Page 6 of 9

V3573 10/10

LONG-TERM SMART

Electronic Delivery Authorization

I agree to receive documents electronically:

Check the

ALL DOCUMENTS

boxes next to

the types of

Quarterly statements

Prospectuses and prospectus supplements

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 Jackson's website. Certain types of correspondence may

provided, but

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

no document

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

type is

selected, the

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

selection will

email address.

default to " All
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.

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.

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.

VDA 123 10/10

Page 7 of 9

V3573 10/10

LONG-TERM SMART

Notice to Applicant

ARKANSAS, COLORADO, KENTUCKY, MAINE, NEW

Insurance within the Department of Regulatory Agencies.

MEXICO, OHIO, PENNSYLVANIA, AND WEST VIRGINIA

DISTRICT OF COLUMBIA RESIDENTS, PLEASE NOTE:

RESIDENTS, PLEASE NOTE: Any person who

WARNING: It is a crime to provide false or misleading

knowingly, and with intent to defraud any insurance

information to an insurer for the purpose of defrauding

company or other person, files an application for

the insurer or any other person. Penalties include

insurance or statement of claim containing any

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

materially false information or conceals for the

deny insurance benefits, if false information materially

purpose of misleading, information concerning any

related to a claim was provided by the applicant.

fact material thereto, commits a fraudulent insurance

NEW JERSEY RESIDENTS, PLEASE NOTE: Any person

act, which is a crime and subjects such person to

who includes any false or misleading information on an

criminal and civil penalties.

application for an insurance policy is subject to criminal

In COLORADO, any insurance company, or agent of an

and civil penalties.

insurance company, who knowingly provides false,

LOUISIANA AND RHODE ISLAND RESIDENTS, PLEASE

incomplete, or misleading facts or information to a

NOTE: Any person who knowingly presents a false or

policyholder or claimant for the purpose of defrauding, or

fraudulent claim for payment of a loss or benefit or

attempting to defraud, the policyholder or claimant with

knowingly presents false information in an application for

regard to a settlement or award payable from insurance

insurance is guilty of a crime and may be subject to fines

proceeds, shall be reported to the Colorado Division of

and confinement in prison.

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 annuity benefits, death benefit values, and withdrawal values, if any, when based on the investment
experience of an Investment Division in the separate account of Jackson, are variable and may be increased or
decreased, and the dollar amounts are not guaranteed.

4. I (We) have been given a current prospectus for this variable annuity and for each available 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 the Contract's Fixed Account Minimum Interest Rate will be determined each Redetermination Date.
The redetermined rate, which may be higher or lower than the Initial Fixed Account Minimum Interest Rate, will apply
for that entire Redetermination Period.

8. 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.)

9. 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.

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 10/10

Page 8 of 9

V3573 10/10

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

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 123 10/10

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