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EXHIBIT 99.(5)
TITANIUM INVESTOR
APPLICATION FOR VARIABLE ANNUITY POLICY United Investors Life Ins. Co.
(Please Print or Type) P.O. Box 12101
Birmingham, AL 35202-2101
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1. ANNUITANT __________________________________________ ______________________________________
Name (First) (Middle) (Last) Social Security No.
Maximum __________________________________ _______________ Sex: ( ) M ( ) F
Issue Age: 90 DOB (Mo/Day/Yr) Age (Last Birthday)
___________________________________________ ___________________________
Street Address (Area Code) Telephone Number
___________________________________________
City State Zip
2. POLICY _________________________________________ ______________________________________
OWNER: Name (First) (Middle) (Last) Social Security No. or Taxpayer ID
Complete if Sex: ( ) M ( ) F
other ______________________________ ___________________
Than Annuitant DOB (Mo/Day/Yr.) Age (Last Birthday)
in
Section 1. ____________________________________________ _________________________
Maximum Issue Street Address (Area Code) Telephone Number
Age: 90 ____________________________________________
City State Zip
3. JOINT
OWNER: _________________________________________ ______________________________________
(If any) Name (First) (Middle) (Last) Social Security No. or Taxpayer ID
______________________________ ___________________ Sex: ( ) M ( ) F
Maximum Issue DOB (Mo/Day/Yr.) Age (Last Birthday)
Age: 90 ____________________________________________ _________________________
Street Address (Area Code) Telephone Number
____________________________________________
City State Zip
____________________________________________
Relationship to Owner
4. BENEFICIARY:
_________________________________________ ______________________________________________
Primary: Name (First) (Middle) (Last) Social Security No. or Taxpayer ID
______________________________ ______________________________________________
DOB (Mo/Day/Yr.) Relationship to Owner
Contingent: _________________________________________ ____________________________
Name (First) (Middle) (Last) Social Security No. or Taxpayer ID
______________________________ ______________________________________________
DOB (Mo/Day/Yr.) Relationship to Owner
5. TYPE OF PLAN:
( ) Non-Qualified:
( )Initial Purchase Payment: $__________(Min. $2,000/$100 Mo.Bank Draft)
( )Monthly Bank Draft Purchase Payments: $__________ (Min. $100 Mo/Complete Bank Draft Form )
( ) Qualified: (Check appropriate box below)
Tax Year for which Contribution is being made ____________
( ) IRA ( ) IRA Rollover ( )IRA Transfer ( ) Roth IRA
( ) Simplified Employee Pension (Where UIL does not act as Custodian.)
( ) Initial Purchase Payment: $__________ (Minimum $1,200 or $100 Mo.Bank Draft or Group Billing)
( ) Monthly Bank Draft Purchase Payments: $__________ (Min. $100 Mo./Complete Bank Draft Form)
( ) Monthly Group Billing Purchase Payments: $__________ (Min. $100 Mo.)
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6. Amount Paid with Application: $__________
Questions 7 and 8 are optional at the time of Application. An Optional
Settlement Election Form must be completed prior to annuitization.
7. Annuity Benefit Date: ______________________________ Age __________
8. Form of Annuity Payments: _________________________
9. Replacement:
a. Are one or more existing life insurance policies or annuity contracts in
force with any insurance company? ( ) Yes ( ) No
b. Is policy applied for intended to replace or change existing insurance
or annuities in force? ( ) Yes ( ) No
(If "Yes", give name of company(s) and policy number(s) below and
enclose any required replacement form.)
Company(s) Policy Number(s)
____________________________________ ______________________________
____________________________________ ______________________________
c. Is this a 1035 exchange? ( ) Yes ( ) No (If "Yes," attach Form U-622)
10. Purchase Payment Allocation (whole percentages only):
AIM V.I. Capital Appreciation Fund ________%
AIM V.I. Growth Fund ________%
AIM V.I. Growth and Income Fund ________%
AIM V.I. International Equity Fund ________%
AIM V.I. Value Fund ________%
Alger American Growth Portfolio ________%
Alger American Income & Growth Portfolio ________%
Alger American Leveraged AllCap Portfolio ________%
Alger American MidCap Growth Portfolio ________%
Alger American Small Capitalization Portfolio ________%
Deutsche VIT EAFE(R) Equity Index ________%
Deutsche VIT Small Cap Index ________%
Dreyfus VIF - Appreciation Portfolio ________%
Dreyfus VIF - Money Market Portfolio ________%
Dreyfus VIF - Quality Bond Portfolio ________%
The Dreyfus Socially Responsible Growth Fund, Inc. ________%
Evergreen VA Equity Index Fund ________%
Evergreen VA Foundation Fund ________%
Evergreen VA Global Leaders Fund ________%
Evergreen VA Small Cap Value Fund ________%
INVESCO VIF - Equity Income Fund ________%
INVESCO VIF - Technology Fund ________%
INVESCO VIF - Utilities Fund ________%
MFS(R) Emerging Growth Series ________%
MFS(R) Growth with Income Series ________%
MFS(R) Research Series ________%
MFS(R) Total Return Series ________%
Strong Discovery Fund II ________%
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Strong Discovery Fund II _____________%
Strong Mid Cap Growth Fund II _____________%
Strong Opportunity Fund II _____________%
Templeton Asset Strategy Fund _____________%
Templeton International Securities Fund _____________%
FIXED ACCOUNT
_____________%
TOTAL
11.( ) Telephone Transfer Authorization: (If selected, Owner must initial
agreement below.)
I agree to hold United Investors Life harmless from all claims when action
is taken pursuant to a telephone transfer request based on the Owner's name
and Policy number. _____________ (Owner's Initials)
UI-500, Ed. 07/00 Page 2
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12.( ) Dollar Cost Averaging: Automatic transfer each month of a pre-selected
amount from the Fixed Account and/or the Money Market Subaccount to any of
the other Subaccounts.
Select Transfer Frequency: ( ) Monthly ( ) Quarterly ( ) Semi-Annual ( )
Annual
Enter day of the month transfers are to be made: ________(1st - 28th). If
the day selected does not fall on a Valuation Date, transfers will be
made on the next following Valuation Date. Transfers will be made at the
unit values determined on the date of each transfer.
Select Transfer Method: (Select one)
( ) Dollar Amount: (Minimum Total Transfer Amount $100)
( ) Fixed Account $______ + ( ) Money Market Subaccount $_____ = Total
Transfer Amount: $______
( ) Percentage Transfer: __________% (Whole percentages only)
Note: If both accounts are selected, the percentage you specify will be
transferred from each account.
( ) Fixed Account and/or ( ) Money Market Subaccount
( ) Reduce Account to Zero over Specified Period: Beginning Date: _________
Ending Date:__________
( ) Fixed Account and/or ( ) Money Market Subaccount
Transfer Amounts to: (If Dollar Amount is selected above, please enter dollar
amounts below with a $25 minimum for each Subaccount selected. If Percentage
Transfer or Reduce Account to Zero over Specified Period is selected, please
enter percentage amounts below. (Percentage amounts must be entered in whole
percentages only and must total 100%.)
AIM V.I. Capital Appreciation Fund _____________
AIM V.I. Growth Fund _____________
AIM V.I. Growth and Income Fund _____________
AIM V.I. International Equity Fund _____________
AIM V.I. Value Fund _____________
Alger American Growth Portfolio _____________
Alger American Income & Growth Portfolio _____________
Alger American Leveraged AllCap Portfolio _____________
Alger American MidCap Growth Portfolio _____________
Alger American Small Capitalization Portfolio _____________
Deutsche VIT EAFE(R) Equity Index _____________
Deutsche VIT Small Cap Index _____________
Dreyfus VIF - Appreciation Portfolio _____________
Dreyfus VIF - Money Market Portfolio _____________
Dreyfus VIF - Quality Bond Portfolio _____________
The Dreyfus Socially Responsible Growth Fund, Inc. _____________
Evergreen VA Equity Index Fund _____________
Evergreen VA Foundation Fund _____________
Evergreen VA Global Leaders Fund _____________
Evergreen VA Small Cap Value Fund _____________
INVESCO VIF - Equity Income Fund _____________
INVESCO VIF - Technology Fund _____________
INVESCO VIF - Utilities Fund _____________
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INVESCO VIF - Utilities _____________
MFS(R) Emerging Growth Series _____________
MFS(R) Growth with Income Series _____________
MFS(R) Research Series _____________
MFS(R) Total Return Series _____________
Strong Discovery Fund II _____________
Strong Mid Cap Growth Fund II _____________
Strong Opportunity Fund II _____________
Templeton Asset Strategy Fund _____________
Templeton International Securities Fund _____________
13.( ) Automatic Asset Rebalancing: Automatic rebalancing of the accounts in
your Policy according to your current Purchase Payment Allocation instructions.
Not available if Dollar Cost Averaging or Interest Sweep is selected.
Select Rebalancing Frequency: ( ) Quarterly ( ) Semi-Annual ( ) Annual
Select Day of Rebalancing: ____________(1st - 28th)
14.( ) Interest Sweep: Automatic transfer of interest from the Fixed Account to
any of the other Subaccounts.
Select Transfer Frequency: ( ) Monthly ( ) Quarterly ( ) Semi-Annual
( ) Annual
Transfer To: (Whole percentages only.)
AIM V.I. Capital Appreciation Fund _____________%
AIM V.I. Growth Fund _____________%
AIM V.I. Growth and Income Fund _____________%
AIM V.I. International Equity Fund _____________%
AIM V.I. Value Fund _____________%
Alger American Growth Portfolio _____________%
Alger American Income & Growth Portfolio _____________%
Alger American Leveraged AllCap Portfolio _____________%
Alger American MidCap Growth Portfolio _____________%
Alger American Small Capitalization Portfolio _____________%
Deutsche VIT EAFE(R) Equity Index _____________%
Deutsche VIT Small Cap Index _____________%
Dreyfus VIF - Appreciation Portfolio _____________%
Dreyfus VIF - Money Market Portfolio _____________%
Dreyfus VIF - Quality Bond Portfolio _____________%
The Dreyfus Socially Responsible Growth Fund, Inc. _____________%
Evergreen VA Equity Index Fund _____________%
Evergreen VA Foundation Fund _____________%
Evergreen VA Global Leaders Fund _____________%
Evergreen VA Small Cap Value Fund _____________%
INVESCO VIF - Equity Income Fund _____________%
INVESCO VIF - Technology Fund _____________%
INVESCO VIF - Utilities Fund _____________%
MFS(R) Emerging Growth Series _____________%
MFS(R) Growth with Income Series _____________%
MFS(R) Research Series _____________%
MFS(R) Total Return Series _____________%
Strong Discovery Fund II _____________%
Strong Mid Cap Growth Fund II _____________%
Strong Opportunity Fund II _____________%
Templeton Asset Strategy Fund _____________%
Templeton International Securities Fund _____________%
TOTAL:
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100%
UI-500, Ed. 07/00 Page 3
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15.Suitability: Owner's Initials
Is the premium shown less than 20% of your net worth?
( ) Yes ( ) No ________________
(If "No," attach Suitability statement signed by
Representative.)
I have received a current prospectus for the variable
annuity and any funds selected. ( ) Yes ( ) No ________________
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To the best of my knowledge and belief, my answers to the questions on this
Application are correct and true. I agree that this Application shall be a part
of any annuity contract issued to me. I also understand that the Company
reserves the right to reject any Application or Purchase Payment. If this
Application is declined, there shall be no liability on the part of the Company
and any Purchase Payments submitted shall be returned.
I UNDERSTAND THAT THE ANNUITY PAYMENTS AND POLICY VALUE WILL INCREASE OR
DECREASE DEPENDING ON THE INVESTMENT PERFORMANCE OF THE SUBACCOUNTS SELECTED.
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Signed At ___________________________________________________ Date __________________________________________
City State (Mo / Day / Year)
________________________________________________ ______________________________________________________
Signature of Owner Signature of Proposed Annuitant (If Other than Owner)
________________________________________________
Signature of Joint Owner (If Any)
________________________________________________ __________ ______________ ___________
_______________
Representative's Name (Please Print) Rep. No. Reg/Div or Branch # Date Phone No.
________________________________________________ ______________________________________________________
Signature of Representative Signature of Principal
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Pre-Authorized Bank Draft Agreement
As a convenience to me, I hereby request and authorize United Investors Life
Insurance Company, Birmingham, Alabama, to initiate premium payments from my
checking account either by electronic funds transfer or by pre-authorized bank
draft order provided there are sufficient collected funds in said account to pay
the same upon presentation. I agree that your rights in respect to each such
transfer or draft shall be the same as if it were a check drawn on you and
signed personally by me. This authority is to remain in effect until revoked by
me in writing; and until you actually receive such notice, I agree that you
shall be fully protected in honoring any such transfer or draft.
I further agree that if any such transfer or draft is dishonored, whether with
or without cause and whether intentionally or inadvertently, you shall be under
no liability whatsoever, even though such dishonor results in the forfeiture of
insurance.
Name of Policyholder(s) Policy Number(s) Bank Draft Premium
______________________ ______________________ ______________________
______________________ ______________________ ______________________
______________________ ______________________ ______________________
Depositor(s) Financial Institution
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_______________________________________________ ____________________________________________
Name of Depositor Listed on the Account (Please print) Name of Financial Institution (Please print)
__________________________________________________ _______ ____________________________________________
Signature of Depositor (as checks are signed) Date Financial Institution Address
__________________________________________________ _______ ____________________________________________
Signature of Joint Depositor (as checks are signed) Date City State Zip Code
Account Number to be Debited___________________________ Please attach a sample "Void" check.
(Deposit slip cannot be used.)
Requested Draft Date (1/st/ through 28/th/ only)___________
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PURCHASE PAYMENT RECEIPT
THE COMPANY DOES NOT INCUR LIABILITY UNDER THIS APPLICATION, OTHER THAN THE
RETURN OF ANY PURCHASE PAYMENTS RECEIVED, UNTIL THE POLICY DATE. ALL CHECKS MUST
BE MADE PAYABLE TO THE COMPANY. DO NOT MAKE CHECK PAYABLE TO THE REPRESENTATIVE
OR LEAVE THE PAYEE BLANK.
__________ ___________________ ____________________________________
Date Amount Paid Representative's Signature
