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The Penn Mutual Life Insurance Company Application for Individual Variable
Philadelphia, PA 19172 and Fixed Deferred Annuity
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1. PLAN: Check One
|_| Diversifier II
|_| Olympia XT |_| Pennant Select |_| Commander Repetitive Contributions
($25,000 minimum) ($5,000 minimum) ($25,000 minimum) SEP, SIMPLE IRA or 403(b) Only
($250 minimum)
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2. MARKET TYPE: Select One
|_| Non-Qualified |_| IRA (Select Type) |_| Rollover |_| Transfer |_| Custodial |_| 403(b) Transfer
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Diversifier II Only (Repetitive Contribution Programs) |_| SEP |_| SIMPLE IRA |_| 403(b) Tax Year ______
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3. OPTIONAL DEATH BENEFITS:
Select One, Standard Benefit if no selection (Not available after age 75 or with Diversifier II)
|_| Annual Step Up |_| Rising Floor at 5% per annum (not available with Olympia XT)
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4. OWNER:
Name Male Female Soc. Sec. or Tax ID #
| | | | -- --
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Permanent Address Phone
( )
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City State Zip Date of Birth
/ /
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5. ANNUITY DATE:
Select Date ______ / 01 / ______ If no date selected, Annuity Date will
be the later of the 1st day of the Annuitant's 95th birthday (85th
birthday for Diversifier II) or 10 years after the issue date.
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6. ANNUITANT: If different than Owner
Name Male Female Soc. Sec. or Tax ID #
| | | | -- --
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Permanent Address Phone
( )
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City State Zip Date of Birth Relation to Owner
/ /
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7. BENEFICIARY: If more than one, indicate % [If 403(b) use PM4799 to designate beneficiaries]
Primary Beneficiary Date of Birth Soc. Sec. or Tax ID # Relation to Owner
/ / -- -- %
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|_| Primary or |_| Contingent Check One Date of Birth Soc. Sec. or Tax ID # Relation to Owner
/ / -- -- %
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|_| Primary or |_| Contingent Check One Date of Birth Soc. Sec. or Tax ID # Relation to Owner
/ / -- -- %
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8. INITIAL PURCHASE PAYMENT: Estimate for exchanges, transfers or rollovers - $____________
Purchase Payment $ ___________________________ Make check payable to:
Complete Section 10A or 10B to establish payment allocation The Penn Mutual Life Insurance Company
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9. DOLLAR COST AVERAGING SOURCE ACCOUNT (DCA):
Optional, Select One, indicate months to allocate, if applicable
|_| 12 Month DCA Account |_| 6 Month DCA Account |_| Limited Maturity Bond
(Olympia XT Only) (Olympia XT and Pennant Select Only) mos to Allocate ______
(12 to 60 mos)
|_| Quality Bond |_| Money Market |_| 1 Year Fixed Interest |_| Holding Account
mos to Allocate ___ mos to Allocate ___ (Commander Only) (Diversifier II Only)
(12 to 60 mos) (12 to 60 mos) mos to Allocate ___ mos to Allocate ____
(12 to 60 mos) (12 to 60 mos)
$ _________ or _________ % of initial premium to be allocated to the DCA source account selected above.
o To direct the DCA payment allocation, list dollars or percentages in the DCA column in 10A below or select one
Portfolio of Funds under 10B.
o If less than total payment is allocated to the DCA source account and you have not selected a Portfolio
of Funds under 10B, allocate the remainder under 10A. (see Payment).
o If you select either the Limited Maturity Bond, Quality Bond or Money Market Fund as your DCA
Source Account, complete 10A to indicate how you want to direct the DCA payment allocation.
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PM0487 Version 8/00 Page 1 of 3
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10. ALLOCATION INFORMATION:
Complete either A or B. For A, indicate whole percentages or dollar amounts
for Payments, whole percentages only for DCA. If providing dollar amounts,
the Payment allocation must equal total payment, less any DCA. For B,
select one Portfolio (allocation percentages recommended by S&P). If DCA
Source Account is the Limited Maturity, Quality Bond or Money Market Funds,
complete A only.
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DCA*
A. (Total 100%)
Investment Option Investment Manager Payments*
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Growth Equity Independence Capital Management, Inc. %/$ %
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VIP Growth Fidelity Management and Research Co. %/$ %
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Mid Cap Growth Turner Investment Partners, Inc. %/$ %
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Emerging Growth RS Investment Management, Inc. %/$ %
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Large Cap Value Putnam Investment Management, Inc. %/$ %
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VIP Equity-Income Fidelity Management and Research Co. %/$ %
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Mid Cap Value Neuberger Berman Management Inc. %/$ %
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Small Cap Value Royce & Associates, Inc. %/$ %
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Index 500 Wells Capital Management Incorporated %/$ %
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International Equity Vontobel USA Inc. %/$ %
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Emerging Markets Equity (Int'l) Morgan Stanley Dean Witter %/$ %
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Quality Bond Independence Capital Management, Inc. %/$ %
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High Yield Bond T. Rowe Price Associates, Inc. %/$ %
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Limited Maturity Bond Independence Capital Management, Inc. %/$ %
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Flexibly Managed T. Rowe Price Associates, Inc. %/$ %
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AMT Balanced Neuberger Berman Management Inc. %/$ %
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VIP II Asset Manager Fidelity Management and Research Co. %/$ %
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Money Market Account Independence Capital Management, Inc. %/$ %
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1 Year Fixed Interest The Penn Mutual Life Insurance Co. %/$ %
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3 Year Fixed Interest The Penn Mutual Life Insurance Co. %/$ %
(Diversifier II Only)
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5 Year Fixed Interest
(Diversifier II Only) ($5,000 minimum) The Penn Mutual Life Insurance Co. %/$ %
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7 Year Fixed Interest
(Diversifier II Only) ($5,000 minimum) The Penn Mutual Life Insurance Co. %/$ %
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Fixed Holding (Diversifier II Only) The Penn Mutual Life Insurance Co. %/$ %
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TOTAL %/$ %
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B. Standard & Poor's -- The Asset Allocation Decision Allocation of Payments and
DCA payments *
|_| Income Portfolio of Funds (Slight risk tolerance or medium time horizon)
|_| Short-Term Growth Portfolio of Funds (Short-term time horizon; average risk
tolerance)
|_| Intermediate Growth Portfolio of Funds (Intermediate time horizon; average
risk tolerance)
|_| Long-Term Growth Portfolio of Funds (Long-term time horizon; above average
risk tolerance)
|_| Aggressive Long-Term Growth Portfolio of Funds (Long-term time horizon; high
risk tolerance)
Note: If you selected the Limited Maturity Bond, Quality Bond or Money
Market Fund as your DCA source account, do not complete section 10B.
Complete 10A with the payment allocation for money moving from the DCA
account.
*Future payments allocation unless directed otherwise is (1) DCA allocation
or (2) if no DCA, Payment allocation.
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11. TELEPHONE REALLOCATION AUTHORIZATION: ___________________ Owner's Initials
I authorize Penn Mutual to act upon reallocation instructions given by
telephone by me or from _____________________ (name of your registered
representative) upon verification of identity. Neither Penn Mutual nor any
person authorized by Penn Mutual will be responsible for any claim, loss,
liability or expense in connection with reallocation instructions received
by telephone from such person if Penn Mutual or such other person acted on
such telephone instructions in good faith in reliance upon this
authorization. Penn Mutual will continue to act upon this authorization
until such time as the person indicated above is no longer affiliated with
the broker/dealer under which my contract was purchased or until such time
that I notify Penn Mutual otherwise in writing.
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PM0487 Version 8/00 Page 2 of 3
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12. REPLACEMENT:
|_| Yes |_| No This Annuity is intended to replace or change existing life
insurance or annuity contract(s). If Yes, list insurance
company(ies) and policy number(s) in the Remarks Section.
Attach state specific replacement forms, if applicable.
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13. NOTICES:
FRAUD -- Any person, who knowingly and with intent to defraud any insurance
company or other person, files an application for insurance or a statement
of claim containing any materially false information or conceals for the
purpose of misleading information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime and subjects such
person to criminal and civil penalties.
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14. ACKNOWLEDGMENT:
I hereby represent that my answers to the above sections are correct and
true to the best of my knowledge and belief. By signing below, I understand
that:
a) The contract value and annuity payments, when based on investment
experience of a separate account, are variable and are not guaranteed as
to a fixed dollar amount;
b) This annuity is a long term commitment to meet insurance needs and
financial goals; I acknowledge receipt of the most recent prospectus of
the product selected which contains all fees and charges associated with
this investment;
c) The annuity applied for is suitable for my investment objectives and my
financial situation and needs; and
d) The owner has the privilege of Telephone Transfers.
VALUES AND PAYMENTS UNDER THIS CONTRACT, WHEN BASED UPON THE INVESTMENT
EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE. THEY MAY DECREASE OR
INCREASE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT.
Signatures:
Signed at:
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City State Date Signed
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Signature of Contract Owner Signature of Annuitant (if
different from Contract Owner)
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15. REGISTERED REPRESENTATIVE:
Do you have any reason to believe the contract applied for is to replace existing insurance or annuities?
|_| Yes |_| No
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Signature of Registered Representative Printed Name of Registered Representative State License Number
(Resident agent if required by law)
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Telephone Number Office Code (3 digit) Representative Code (5 digit)
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Office/Firm Name Broker / Dealer Name
Commission Option Selected (Pennant Select or Olympia XT Only) (Choose 1,2 or 3) __________ (Default is 1)
Office Code (3 Servicing Agent (select
Registered Representative digit) Representative Code (5 digit) Percent (%) one)
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16. SEND APPLICATION, CHECK & OTHER REQUIRED FORMS TO:
The Penn Mutual Life Insurance Company, 600 Dresher Road - C2L, Horsham, PA 19044
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17. REMARKS:
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PM0487 Version 8/00 Page 3 of 3
