EX-99.5.(A)(2) 4 dex995a2.txt FORM OF VARIABLE ANNUITY APPLICATION (FORM NO. 25-17810) EXHIBIT 5(a)(2) Pacific Life Insurance Company PACIFIC ODYSSEY [LOGO] PACIFIC LIFE P.O. Box 7187 . Pasadena, CA 91109-7187 Variable Annuity www.PacificLife.com . (800) 722-2333 Application
Call (800) 722-2333 if you need assistance. 1. ANNUITANT Annuitant(s) must be an individual. Check product guidelines for maximum issue age. ----------------------------------------------------------------- -------------------------------------- ------------ Name (First, Middle Initial, Last) Birth Date (mo/day/yr) Sex John R. Doe 01/01/1967 [X] M [ ] F ----------------------------------------------------------------- -------------------------------------- ------------ -------------------------------------------------------- ---------------------------------------------- ------------- Street Address City, State, ZIP SSN 555 Main Street Anytown, USA 12345 ###-##-#### -------------------------------------------------------- ---------------------------------------------- ------------- ------------------- Solicited at: State Complete this box for custodial-owned qualified contracts only. Will not be valid for any other contract types. Information put here will be used for contract and agent appointment purposes. -------- -------- ------------------- ADDITIONAL ANNUITANT Not applicable for qualified contracts. Check One: [X] Joint [ ] Contingent ----------------------------------------------------------------- -------------------------------------- ------------ Name (First, Middle Initial, Last) Birth Date (mo/day/yr) Sex Jane A. Doe 01/01/1967 [ ] M [X] F ----------------------------------------------------------------- -------------------------------------- ------------ -------------------------------------------------------- ---------------------------------------------- ------------- Street Address City, State, ZIP SSN 555 Main Street Anytown, USA 12345 ###-##-#### -------------------------------------------------------- ---------------------------------------------- ------------- 2. OWNER If annuitant and owner are the same, it is not necessary to complete this section. Check product guidelines for maximum issue age. Additional forms may be necessary if owner is a trust or other non-natural entity. See instruction page for more information. ----------------------------------------------------------------- -------------------------------------- ------------ Name (First, Middle Initial, Last) Birth Date (mo/day/yr) Sex [ ] M [ ] F ----------------------------------------------------------------- -------------------------------------- ------------ -------------------------------------------------------- ---------------------------------------------- ------------- Street Address City, State, ZIP SSN/TIN -------------------------------------------------------- ---------------------------------------------- ------------- ADDITIONAL OWNER Not applicable for qualified contracts. Check One: [ ] Joint [ ] Contingent ----------------------------------------------------------------- -------------------------------------- ------------ Name (First, Middle Initial, Last) Birth Date (mo/day/yr) Sex [ ] M [ ] F ----------------------------------------------------------------- -------------------------------------- ------------ -------------------------------------------------------- ---------------------------------------------- ------------- Street Address City, State, ZIP SSN/TIN -------------------------------------------------------- ---------------------------------------------- ------------- 3. BENEFICIARIES If no boxes are checked, default will be primary beneficiaries. For non-individually owned custodially held IRAs, 457 and qualified plans, if no beneficiary is listed, the beneficiary will default to the owner listed on the application. Unless otherwise indicated, proceeds will be divided equally. Use Special Requests section to provide additional beneficiaries or beneficiary information. -------------------------------------------------------- -------------- ------------------ ----------- ---------- Name (First, Middle Initial, Last) [X] Primary Relationship SSN/TIN Percentage Mary S. Doe [ ] Contingent Daughter ###-##-#### 100% -------------------------------------------------------- -------------- ------------------ ----------- ---------- -------------------------------------------------------- -------------- ------------------ ----------- ---------- Name (First, Middle Initial, Last) [ ] Primary Relationship SSN/TIN Percentage [ ] Contingent % -------------------------------------------------------- -------------- ------------------ ----------- ---------- 4. CONTRACT TYPE Select ONE. 5. INITIAL PURCHASE PAYMENT Make check payable to Pacific Life Insurance Company. ------------------------------------- 5A. NON-QUALIFIED CONTRACT PAYMENT TYPE Indicate the type of initial payment. [X] Non-Qualified [ ] 401(a)/2/ --------------------------------------------------------------------------------- [ ] IRA [ ] 401(k)/2/ [ ] 1035 exchange/estimated transfer .................................. $______ [ ] SIMPLE IRA/1/ [ ] 457 [X] Amount enclosed ................................................... $25,000 [ ] SEP-IRA [ ] Keogh/HR10/2/ --------------------------------------------------------------------------------- [ ] Roth IRA [ ] TSA/403(b)/3/ 5B. QUALIFIED CONTRACT PAYMENT TYPE Indicate the type of initial payment. ------------------------------------- If no year is indicated, contribution defaults to current tax year. --------------------------------------------------------------------- /1/ Complete SIMPLE IRA Employer Information form [ ] Transfer............ $_____________ /2/ Complete Qualified Plan Disclosure form. [ ] Rollover............ $_____________ /3/ Complete TSA Certification form. [ ] Contribution........ $_____________ for tax year_____________ ---------------------------------------------------------------------
6. REPLACEMENT Will the purchase of this annuity result in the replacement, termination or ---------------------------- change in value of any existing life insurance or annuity in this or any other company? Contract Type Being Replaced [ ] Yes [X] No If yes, provide the information below and attach any required state replacement and/or 1035 exchange/transfer forms. Use the Special Requests section to [ ] Life Insurance provide additional insurance companies and contract numbers. ---------------------------------------------------------------- ----------------------- [ ] Fixed Annuity Insurance Company Name Contract Number [ ] Variable Annuity ---------------------------------------------------------------- ----------------------- ---------------------------- 7. AVAILABLE OPTIONS 7A. DEATH BENEFIT COVERAGE Subject to state availability. Annuitant(s) must not be over age 75 at issue for the Stepped-Up Death Benefit. If the option is not selected, the Standard Death Benefit is the default. --------------------------------------------------------- [X] Standard Death Benefit [ ] Stepped-Up Death Benefit --------------------------------------------------------- 7B. TELEPHONE/ELECTRONIC TRANSACTION AUTHORIZATION I will receive this privilege automatically. By checking "yes," I am also authorizing and directing Pacific Life to act on telephone or electronic instructions from any other person(s) who can furnish proper identification. Pacific Life will use reasonable procedures to confirm that these instructions are authorized and genuine. As long as these procedures are followed, Pacific Life and its affiliates and their directors, trustees, officers, employees, representatives and/or agents, will be held harmless for any claim, liability, loss or cost. [X] Yes 7C. ELECTRONIC DELIVERY AUTHORIZATION By checking "yes," I authorize Pacific Life to provide my statements, prospectuses and other information (documents) electronically instead of sending paper copies of these documents by U.S. mail. I will continue to receive paper copies of annual statements via U.S. mail. I understand that I must have internet access and provide my e-mail address below to use this service and there may be access fees charged by the internet service provider. [X] Yes --------------------------------------------------------- Email address: JDoe@aol.com --------------------------------------------------------- 8. ALLOCATION OPTIONS Use whole percentages only. Allocations must total 100%. Complete Transfers and Allocations form for dollar cost averaging and rebalancing. ------------------------------------------------------------------------------------------------------------------------- Manager: Investment Option: [LOGO] AIM INVESTMENTS(SM) ________% Blue Chip ________% Aggressive Growth 10 % Diversified Research [LOGO] CAPITAL GUARDIAN ________% Small-Cap Equity ________% International Large-Cap [LOGO] GOLDMAN SACHS ________% Short Duration Bond ASSET MANAGEMENT ________% I-Net Tollkeeper (SM) ________% Financial Services ________% Health Sciences [LOGO] INVESCO ________% Technology ________% Telecommunications [LOGO] JANUS ________% Growth LT ________% Focused 30 [LOGO] LAZARD ________% Mid-Cap Value 40 % International Value [LOGO] MFS INVESTMENT MANAGEMENT(R) ________% Capital Opportunities ________% Global Growth [LOGO] MERCURY ADVISORS ________% Equity Index ________% Small-Cap Index 20 % Multi-Strategy [LOGO] OPPENHEIMERFUNDS(R) ________% Main Street(R) Core ________% Emerging Markets [LOGO] PIMCO ________% Inflation Managed ________% Managed Bond [LOGO] NFJ ________% Small-Cap Value ________% Equity Income ________% Research [LOGO] PUTNAM INVESTMENTS ________% Equity ________% Aggressive Equity [LOGO] SALOMON BROTHERS ASSET MANAGEMENT ________% Large-Cap Value ________% Comstock [LOGO] VAN KAMPEN ________% Real Estate ________% Mid-Cap Growth ________% Money Market [LOGO] PACIFIC LIFE ________% High Yield Bond 30 % DCA Plus Fixed Option with a Guarantee Term of 6 months + MUST TOTAL 100% 100 + Must complete DCA section of Transfers and Allocations form. -------------------------------------------------------------------------------------------------------------------------
9. SPECIAL REQUESTS If additional space is needed, attach letter signed and dated by owner(s). ------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------- 10. STATEMENT OF OWNER I, the owner(s), understand that I have applied for an individual flexible premium deferred variable annuity contract ("contract") issued by Pacific Life Insurance Company ("company"). I received prospectuses for this variable annuity contract. After reviewing my financial background with my agent, I believe this contract will meet my insurable needs and financial objectives. If applicable, I considered the appropriateness of full or partial replacement of any existing life insurance or annuity. I UNDERSTAND THAT BENEFITS AND VALUES PROVIDED UNDER THE CONTRACT MAY BE ON A VARIABLE BASIS. AMOUNTS DIRECTED INTO ONE OR MORE VARIABLE INVESTMENT OPTIONS WILL REFLECT THE INVESTMENT EXPERIENCE OF THOSE INVESTMENT OPTIONS. THESE AMOUNTS MAY INCREASE OR DECREASE, AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. I have discussed all fees and charges for this contract with my agent. If there are joint owners, the issued contract will be owned by the joint owners as Joint Tenants With Right of Survivorship and not as Tenants in Common. I certify, under penalties of perjury, that I am a U.S. person (including a U.S. resident alien) and that the taxpayer identification number is correct. These states require insurance companies to provide a fraud Virginia It is a crime to knowingly provide false, warning statement. Please refer to the fraud warning incomplete or misleading information to an insurance statement for your state as indicated below. Please check company for the purpose of defrauding the company. for state product availability. Penalties include imprisonment, fines and denial of insurance benefits. Colorado It is unlawful to knowingly provide false, All Other States: Any person who knowingly and with intent incomplete, misleading facts or information to an insurance to defraud any insurance company or other person files an company for the purpose of defrauding or attempting to application for insurance or statement of claim containing defraud the company. Penalties may include imprisonment, any materially false information or conceals for the fines, denial of insurance and civil damages. Any insurance purpose of misleading, information concerning any fact company or agent of an insurance company who knowingly material thereto commits a fraudulent insurance act, which provides false, incomplete or misleading facts or may be a crime and may subject such person to criminal and information to a policyholder or claimant for the purpose civil penalties. of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from ---------------------------------------- ---------------- insurance proceeds shall be reported to the Colorado Owner's Signature Date (mo/day/yr) Division of Insurance within the Department of Regulatory SIGN HERE /s/ John R. Doe 03/01/2003 Services. ---------------------------------------- ---------------- --------------------------------------------- ----------- ---------------------------------------- ---------------- Signed at: City State Joint Owner's Signature if applicable Date (mo/day/yr) Orange C A SIGN HERE /s/ Jane A. Doe 03/01/2003 --------------------------------------------- ----------- ---------------------------------------- ---------------- 11. AGENT'S STATEMENT Do you have reason to believe that any existing life insurance policy or annuity contract has been (or will be) surrendered, withdrawn from, loaned against, changed or otherwise reduced in value, or replaced in connection with this transaction assuming the contract applied for will be issued? If yes, explain in --------------- Replacement Section. I have explained to the owner(s) how the annuity will meet their insurable needs [ ] Yes [X] No and financial objectives. I have discussed the appropriateness of replacement, and followed Pacific --------------- Life's written replacement guidelines. MUST CHECK ONE ----------------------------------------------- --------------------------------------- ----------------------------- Soliciting Agent's Signature Print Agent's Full Name Agent's ID Number SIGN HERE /s/ Cindy Brown Cindy Brown ###-##-#### ----------------------------------------------- --------------------------------------- ----------------------------- ----------------------------------------------- --------------------------------------- Agent's Phone Number Agent's E-Mail Address 213-495-0111 ----------------------------------------------- --------------------------------------- ----------------------------------------------- --------------------------------------- Broker/Dealer's Name Brokerage Account Number Optional. Brown & Associates ----------------------------------------------- --------------------------------------- Send completed application as follows: APPLICATIONS WITH PAYMENT: Regular Mail Delivery: P.O. Box 100060, Pasadena, CA 91189-0060 Express Mail Delivery: 1111 S. Arroyo Parkway, Ste. 205, Pasadena, CA 91105 APPLICATIONS WITHOUT PAYMENT: Regular Mail Delivery: P.O. Box 7187, Pasadena, CA 91109-7187 Express Mail Delivery: 1111 S. Arroyo Parkway, Ste. 205, Pasadena, CA 91105
APPLICATION INSTRUCTIONS Pacific Life Insurance Company PACIFIC ODYSSEY [LOGO] PACIFIC LIFE P.O. Box 7187 . Pasadena, CA 91109-7187 Variable Annuity www.PacificLife.com . (800) 722-2333 [LETTERHEAD] PACIFIC LIFE
Section Use these instructions when completing the Pacific Odyssey application 1. & 2. Annuitants/Owners: Check product guidelines for maximum issue age. When setting up annuity contracts, there are many combinations of owner and annuitant registrations which may result in different death benefit consequences. For example, the death of an owner/ annuitant may have different consequences than the death of a non-owner annuitant. Consult prospectus for additional information. For qualified contracts, there cannot be joint or contingent owners and/or joint annuitants. Spousal signatures may be required for certain actions in qualified contracts. This contract is not intended for use in group unallocated plans. For 401(a) pension/profit sharing, 401(k) and 457 plans, name plan as owner, and participant as sole annuitant. For 403(b) plans, name participant as both sole owner and sole annuitant. For Inherited 403(b)s, also complete and attach the appropriate Inherited IRA or Inherited TSA/403(b) Certification form. For IRAs (except Inherited IRAs), owner and annuitant should be the IRA owner. For Inherited IRAs, also complete and attach the appropriate Inherited IRA or Inherited TSA/403(b) Certification form and see the Inherited IRA Checklist for owner/annuitant information. For nonqualified contracts only, if owner is a non-natural person or corporation, also complete the Non-Natural or Corporate-Owned Disclosure Statement. If trust is owner (other than Charitable Remainder Trust), also complete Trust Agreement Certification form. Consult a tax adviser to properly structure annuity contracts and effect transfers. Complete the "Solicited at: State" box for custodial owned contracts only. 3. Beneficiaries: Indicate the person(s) or entity(ies) to be designated as beneficiary(ies). If no beneficiary(ies) is indicated, the provisions of the contract will govern as to the payment of any death benefit proceeds. 4. Contract Type: Check the type of annuity contract to be issued. Complete appropriate form indicated. If initial IRA payment represents both a rollover and a contribution, indicate amounts for each. Pacific Life will only act as a non-designated financial institution. 5. Initial Purchase Payment: Indicate the amount of the initial purchase payment in U.S. dollars. The minimum initial purchase payment is $25,000. Transfer indicates a trustee to trustee or custodian to custodian transfer only. 6. Replacement: Complete and attach a Transfer/Exchange form and any required state replacement forms. 7. Available Options 7A. Death Benefit Coverage (Optional): Must be chosen at time of issue. If an option is not selected, the Standard Death Benefit will apply. Consult prospectus for charges and details. 7B. Telephone/Electronic Transaction Authorization (Optional): By checking this box you authorize Pacific Life to receive certain instructions by telephone or electronically from your designee. This instruction is valid until you instruct us otherwise. Telephone/Electronic contract changes will be subject to the conditions of the contract, the administrative requirements of Pacific Life, and the provisions set forth in the contract's prospectus. 7C. Electronic Delivery Authorization (Optional): Complete this section to receive statements, prospectuses and other information electronically from out Web site. This instruction is valid until you instruct us otherwise. 8. Allocation Options: Choose one or more investment options to which all or a portion of the initial purchase payment may be allocated. Use whole percentages only. Allocation percentages must total 100%. If choosing the DCA Plus Fixed Option: (a) indicate a 6- or 12- month guarantee term, and (b) complete the DCA section of the Transfers and Allocations form and submit with application. Only one guarantee term may be in effect at any given time. 9. Special Requests: Use this section to indicate special registrations, additional beneficiaries or other instructions. 10. Statement Of Owner(s): Read this section carefully. This application must be signed and dated by the owner. In cases of joint ownership, both owners must sign. Indicate city and state where the application is signed. 11. Agent's Statement: Agent must fully complete and sign this section. Important: Help avoid a returned application by confirming your application has the following minimum information: . Annuitant and owner information - Sections 1 & 2 . Line of business is correct - Section 4 . City and state where application is signed - Section 10 . Date application is signed - Section 10 . Agent's signature - Section 11