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EXHIBIT (5)(a)
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FORM OF APPLICATION
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Application for variable annuity
Issued by: PFL Life Insurance Company ("PFL Life") 4333 Edgewood Road N.E.,
Cedar Rapids, IA 52499-0001 Mail the application and a check: PFL Life Insurance
Company. Attn: Variable Annuity Department
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1. OWNER
If no annuitant is
specified in #2, the
Owner will be the
Annuitant.
In the event the owner is a verification of trust, please provide trustees.
Name: Phone No.:
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Address: City: State: Zip:
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[ ] Male [ ] Female SS#/TIN[ ][ ][ ]-[ ][ ]-[ ][ ][ ][ ] Birthdate [ ][ ]/[ ][ ]/[ ][ ][ ][ ]
JOINT OWNER(S)
Name: Phone No.:
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Address: City: State: Zip:
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[ ] Male [ ] Female SS#/TIN[ ][ ][ ]-[ ][ ]-[ ][ ][ ][ ] Birthdate [ ][ ]/[ ][ ]/[ ][ ][ ][ ]
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2. ANNUITANT
Complete only if
different from Owner.
Name: Relationship to Owner:
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Address: City: State: Zip:
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[ ] Male [ ] Female SS#/TIN[ ][ ][ ]-[ ][ ]-[ ][ ][ ][ ] Birthdate [ ][ ]/[ ][ ]/[ ][ ][ ][ ]
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3. BENEFICIARY(IES)
<S> <C> <C>
Primary: Relationship to Annuitant: %
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Primary: Relationship to Annuitant: %
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Contingent: Relationship to Annuitant: %
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Contingent: Relationship to Annuitant: %
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4. TELEPHONE TRANSFERS
Following is authorized to make telephone transfer requests (check one only):
[ ] Owner(s) only, or
[ ] Owner(s) and Owner's Registered Representative (Print Rep Name)
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5. ALLOCATION OF PREMIUM PAYMENTS
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Initial Premium
$
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Make check payable
to PFL Life Insurance
Company.
Type of Annuity;
[ ] Non-qualified
Qualified Types:
Also complete Section 6.
[ ] IRA
[ ] Roth IRA
[ ] SEP/IRA
[ ] 403(b)
[ ] Keogh
[ ] Roth Conversion
[ ] Other
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Please check selected funds and fixed accounts. The initial premium will be
allocated as selected here. If Dollar Cost Averaging, see section 7 on reverse
side.
FA International Portfolio % Fixed Accounts:
-------
FA Large Cap Growth Portfolio % DCA (Dollar Cost Averaging) Acct. %
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FA Mid Cap Growth Portfolio % 1 - Year Fixed %
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FA Small Cap Growth Portfolio % 3 - Year Fixed Not available
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FA Technology Portfolio % 5 - Year Fixed %
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7 - Year Fixed Not available
Federated Prime Money II %
-------
Money Market Account %
-------
Putnam VT Diversified Income Fund %
-------
Putnam VT The George Putnam Fund of Boston %
-------
Putnam VT Growth and Income Fund %
-------
Putnam VT Income Fund %
-------
Putnam VT Investors Fund %
-------
Putnam VT New Value Fund %
-------
. Policy values, when allocated to any of the Variable Options are not
guaranteed as to dollar fixed amount.
. When funds are allocated to Fixed Account Guarantee Periods, policy values
under policy may increase or decrease in accordance with Excess Interest
Adjustment prior to the end Guarantee of Period.
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6. QUALIFIED PLAN INFORMATION
IRA / SEP / ROTH IRA
$ Contribution for tax year
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$ Trustee to Trustee Transfer
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$ Rollover from [ ] IRA [ ] 403(b) [ ] Pension
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[ ] Other
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ROTH IRA Rollover
Date first established
[ ][ ]/[ ][ ]/[ ][ ][ ][ ] or date of conversion
$ Portion previously taxed
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RBKVA-APP R299
Principal-Plus Variable Annuity
Standard Application
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7. DOLLAR COST AVERAGING PROGRAM
Authorized by Owner
signature in Section 11.
Transfer Frequency : Transfer to (indicate investment option and percentage):
<S> <C> <C> <C> <C>
DCA Program Options .0% .0%
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[ ] 6 month program .0% .0%
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[ ] 12 month program
Number of transfers .0% .0%
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Other Frequency Options .0% .0%
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[ ] Monthly (6 min, 24 max) .0% .0%
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[ ] Quarterly (4 min, 8 max) .0% .0%
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Total: 100%
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8. OTHER
Family Income Protector Option:
[ ] No [ ] Yes (Available at an additional cost, see prospectus)
Please complete.
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9. MINIMUM DEATH BENEFIT
Select one.
Your selection cannot be changed after the policy has been issued. If no option
specified, Option A will apply.
[ ] Option A- Return of Premium Death Benefit. Annual Mortality and Expense
(M&E) Risk Fee and Administrative Charge is 1.25%.
[ ] Option B- 5% Annually Compounding Death Benefit. Maximum Annuitant issue
age of 80: Annual M&E Risk Fee and Administrative Charge is 1.40%.
[ ] Option C- Annual Step-Up Death Benefit. Maximum Annuitant issue age of
80: Annual M&E Risk Fee and Administrative Charge is 1.40%.
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10.REPLACEMENT INFORMATION
Will this annuity replace or change any existing annuity or life insurance?
[ ] No [ ] Yes (If Yes, complete the following)
Company: Policy No.:
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11. SIGNATURE(S) OF AUTHORIZATION ACCEPTANCE
. Unless I have notified the Company of a community or marital property
interest in this policy, the Company will rely on a good faith belief that
no such interest exists and will assume no responsibility for inquiry.
. To the best of my knowledge and belief, my answers to the questions on this
application are correct and true, and I agree that this application becomes
a part of the annuity policy when issued to me.
. I (we) am in receipt of a current prospectus for this variable annuity.
. This application is subject to acceptance by PFL Life. If this application
is rejected for any reason, PFL Life will be liable only for return of
premiums paid.
[ ] Check here if you want to be sent a copy of Statement of Additional
Information.
I HAVE REVIEWED MY EXISTING ANNUITY COVERAGE AND FIND THIS POLICY SUITABLE FOR
MY NEEDS.
Signed at: City: State: Date:
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Owner(s): Annuitant (if not Owner):
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12. AGENT INFORMATION
Do you have any reason to believe the annuity applied for will replace or change
any existing annuity or life insurance? [ ] No [ ] Yes
I HAVE REVIEWED THE APPLICANT'S EXISTING ANNUITY COVERAGE AND FIND THIS POLICY
IS SUITABLE FOR HIS/HER NEEDS.
Registered Representative/
Licensed Agent Name (please print): Signature:
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Phone No.: SS#/TIN [ ][ ][ ]-[ ][ ]-[ ][ ][ ][ ]
[ ] A [ ] B [ ] C
PFL Life Agent #: N/A
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Firm Name: US Bancorp Investments
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Firm Address: N/A
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