EXHIBIT 5
FORM OF APPLICATION
<PAGE>
<
<TABLE>
<S> <C> <C>
[Logo] PHOENIX PHOENIX HOME LIFE MUTUAL INSURANCE COMPANY PHOENIX INCOME ADVANTAGE(SM)
REGULAR MAIL: Phoenix Variable Products Mail Operation IMMEDIATE ANNUITY APPLICATION
PO Box 8027, Boston MA 02266-8027
EXPRESS MAIL: Phoenix Home Life Mutual Insurance Company
66 Brooks Drive, Braintree MA 02184
</TABLE>
===============================================================================
1. ANNUITANT
-------------------------------------------------------------------------------
Name (Print as desired in contract)
-------------------------------------------------------------------------------
Social Security Number _ _ _ - _ _ - _ _ _ _
-------------------------------------------------------------------------------
Date of Birth Sex [ ] Male
[ ] Female
-------------------------------------------------------------------------------
Address (Number and Street)
-------------------------------------------------------------------------------
City State ZIP Code
-------------------------------------------------------------------------------
Phone _ _ _ / _ _ _ - _ _ _ _
-------------------------------------------------------------------------------
2. JOINT ANNUITANT - (Payment Options C and D ONLY)
-------------------------------------------------------------------------------
Name
-------------------------------------------------------------------------------
Social Security Number _ _ _ - _ _ - _ _ _ _
-------------------------------------------------------------------------------
Date of Birth Sex [ ] Male
[ ] Female
-------------------------------------------------------------------------------
Address (Number and Street)
-------------------------------------------------------------------------------
City State ZIP Code
-------------------------------------------------------------------------------
Phone _ _ _ / _ _ _ - _ _ _ _
-------------------------------------------------------------------------------
3. OWNER
------------------------------------------------------------------------------
Name (Print as desired in contract)
-------------------------------------------------------------------------------
Social Security Number/
Federal I.D. _ _ _ - _ _ - _ _ _ _
-------------------------------------------------------------------------------
Date of Birth Sex [ ] Male
[ ] Female
-------------------------------------------------------------------------------
Address (Number and Street)
-------------------------------------------------------------------------------
City State ZIP Code
-------------------------------------------------------------------------------
Phone _ _ _ / _ _ _ - _ _ _ _
-------------------------------------------------------------------------------
4. JOINT OWNER - (If any)
-------------------------------------------------------------------------------
Name
-------------------------------------------------------------------------------
Social Security Number/
Federal I.D. _ _ _ - _ _ - _ _ _ _
-------------------------------------------------------------------------------
Date of Birth Relationship to Owner Sex
[ ] Male
[ ] Female
-------------------------------------------------------------------------------
5. PROOF OF AGE - (Required for Life and Joint Life Options)
-------------------------------------------------------------------------------
[ ] Annuitant [ ] Joint Annuitant
(Submit copy of Birth Certificate or Driver's License)
-------------------------------------------------------------------------------
6. BENEFICIARY DESIGNATION
-------------------------------------------------------------------------------
Name
-------------------------------------------------------------------------------
Relationship
%
-------------------------------------------------------------------------------
Name
-------------------------------------------------------------------------------
Relationship
%
-------------------------------------------------------------------------------
Name
-------------------------------------------------------------------------------
Relationship
%
-------------------------------------------------------------------------------
7. PAYMENT OPTIONS
-------------------------------------------------------------------------------
[ ] Option A - Single Life Annuity
{ ] Option B - Single Life Annuity with Period Certain
[ ] 10 yr Certain [ ] 15 yr Certain [ ] 20 yr Certain
[ ] Option C - Joint Survivor Life Annuity
Percent to Survivor [ ] 50% [ ] 100%
[ ] Option D - Joint Survivor Life Annuity with Period Certain
[ ] 10 yr Certain [ ] 15 yr Certain [ ] 20 yr Certain
Percent to Survivor [ ] 50% [ ] 100%
[ ] Option E - Annuity for a Specified Period
_________ Number of years (5 to 30)
[ ] Option F - Life Expectancy Annuity
[ ] Option G - Unit Refund Life Annuity
-------------------------------------------------------------------------------
8. GUARANTEED MINIMUM PAYMENT RIDER - (Not available in all states)
-------------------------------------------------------------------------------
[ ] Yes, I elect this optional rider. Election of this rider restricts your
selection of Payment Options, AIR and Premium Allocation.
-------------------------------------------------------------------------------
9. ASSUMED INTEREST RATE (AIR) - (Required if Variable Annuity Payments are
elected)
-------------------------------------------------------------------------------
[ ] 3% or [ ] 5%
Used to establish the initial Variable Annuity Payment and cannot be
changed once selected.
-------------------------------------------------------------------------------
10. PLAN TYPE - (Select one)
-------------------------------------------------------------------------------
[ ] Nonqualified [ ] 1035 Exchange $_______________
Cost Basis
[ ] Transfer/Rollover IRA
[ ] Traditional [ ] SEP [ ] Simple [ ] Roth
[ ] 403(b) Rollover [ ] 401(a) Qualified Plan
Estimated Transfer Amount $_______________
-------------------------------------------------------------------------------
This application and contract which is attached to this application, is the
entire contract between you and us.
OL3140 1 11-00
<PAGE>
================================================================================
11. PREMIUM WITH APPLICATION
-------------------------------------------------------------------------------
Premium with Application $_______________
Make Premium Payment check payable to "PHOENIX".
PREMIUM ALLOCATION
Fixed Income Allocation ______%*
Variable Payment Allocation ______%**
100%
Amount allocated to Variable Annuity Payments should be invested as follows:
_____ % Phoenix-Aberdeen International
_____ % Phoenix-Aberdeen New Asia
_____ % Phoenix-Bankers Trust Dow 30
_____ % Phoenix-Bankers Trust Nasdaq-100 Index(R)
_____ % Phoenix-Duff & Phelps Real Estate Securities
_____ % Phoenix-Engemann Capital Growth
_____ % Phoenix-Engemann Nifty-Fifty
_____ % Phoenix-Engemann Small & Mid-Cap Growth
_____ % Phoenix-Federated US Govt Bond
_____ % Phoenix-Goodwin Money Market
_____ % Phoenix-Goodwin Multi-Sector Fixed Income
_____ % Phoenix-Hollister Value Equity
_____ % Phoenix-J.P. Morgan Research Enhanced Index
_____ % Phoenix-Janus Equity Income
_____ % Phoenix-Janus Flexible Income
_____ % Phoenix-Janus Growth
_____ % Phoenix-Morgan Stanley Focus Equity
_____ % Phoenix-Oakhurst Balanced
_____ % Phoenix-Oakhurst Growth and Income
_____ % Phoenix-Oakhurst Strategic Allocation
_____ % Phoenix-Sanford Bernstein Global Value
_____ % Phoenix-Sanford Bernstein Mid-Cap Value
_____ % Phoenix-Sanford Bernstein Small-Cap Value
_____ % Phoenix-Seneca Mid-Cap Growth
_____ % Phoenix-Seneca Strategic Theme
_____ % Alger American Leveraged AllCap Portfolio
_____ % EAFE(R) Equity Index Fund
_____ % Federated Fund for US Government Securities II
_____ % Federated High Income Bond Fund II
_____ % Fidelity VIP Contrafund(R) Portfolio
_____ % Fidelity VIP Growth Opportunities Portfolio
_____ % Fidelity VIP Growth Portfolio
_____ % Technology Portfolio
_____ % Mutual Shares Securities Fund - Class 2
_____ % Templeton Asset Strategy Fund - Class 2
_____ % Templeton Developing Markets Securities Fund - Class 2
_____ % Templeton Growth Securities Fund - Class 2
_____ % Templeton International Securities Fund- Class 2
_____ % Wanger Foreign Forty
_____ % Wanger International Small Cap
_____ % Wanger Twenty
_____ % Wanger US Small Cap
_____ TOTAL
--------------------------------------------------------------------------------
12. PAYMENT FREQUENCY
--------------------------------------------------------------------------------
[ ] Monthly [ ] Level Monthly [ ] Quarterly
[ ] Semi-Annual [ ] Annual
[ ] Annuity Direct Deposit (complete separate Bank Authorization form)
NOTE: Your first Annuity Payment will be one month following your Contract Date,
regardless of the mode selected.
--------------------------------------------------------------------------------
13. REPLACEMENT
--------------------------------------------------------------------------------
Will this annuity replace any existing life insurance or annuity?
[ ] Yes [ ] No Details: ________________________________________________________
Company _____________________________________________________________________
Policy No. _____________________________________________________________________
--------------------------------------------------------------------------------
14. SPECIAL REMARKS
--------------------------------------------------------------------------------
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
--------------------------------------------------------------------------------
15. TAX WITHHOLDING INFORMATION
--------------------------------------------------------------------------------
Your payments are subject to income tax withholding unless you elect not to have
withholding apply. Withholding applies only to the portion of your payment that
is subject to federal income tax. You may elect not to have withholding apply by
checking the box below. Your election will remain in effect until revoked. If
you elect no withholding, or if you do not have enough tax withheld from your
distribution, you may have to pay an estimated tax. If your withholding and
estimated tax payments are insufficient, you may be penalized under the
estimated tax rules. You may revoke your election at any time. Other federal or
state mandatory withholding rules may apply to certain distributions.
FEDERAL INCOME TAX WITHHOLDING (select one)
[ ] NO, I/we do not want to have Federal Income Tax withheld. OR
[ ] YES, I/we want Federal Income Tax withheld.
MARITAL STATUS
[ ] Single [ ] Married [ ] Married, but withhold at higher Single rate.
[bullet] Number of allowances ____________
[bullet] I want an additional amount withheld from each Annuity Payment
$ ____________
--------------------------------------------------------------------------------
16. PAYEE INFORMATION - (If left blank, Annuitant will be considered payee)
--------------------------------------------------------------------------------
1. Name (Print First, MI, Last) %
--------------------------------------------------------------------------------
Address (Number and Street)
--------------------------------------------------------------------------------
City State ZIP Code
--------------------------------------------------------------------------------
2. Name (Print First, MI, Last) %
--------------------------------------------------------------------------------
Address (Number and Street)
--------------------------------------------------------------------------------
City State ZIP Code
--------------------------------------------------------------------------------
* No transfers may be made from the Fixed Income Allocation to the
Subaccounts.
** Once each contract year, you may transfer all or a portion of the value of
the Subaccounts to the Fixed Income Allocation.
OL3140 2 11-00
<PAGE>
================================================================================
OWNER(S) ACKNOWLEDGEMENTS
--------------------------------------------------------------------------------
[ ] I WOULD LIKE TO RECEIVE A STATEMENT OF ADDITIONAL INFORMATION (SAI).
[ ] I/WE HAVE READ THE DISCLOSURE STATEMENT ABOVE.
I/WE UNDERSTAND THAT ANNUITY PAYMENTS OR SURRENDER VALUES, WHEN BASED UPON THE
INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT ARE VARIABLE AND NOT GUARANTEED AS
TO A FIXED DOLLAR AMOUNT.
I have read the above statements and represent that they are complete and true
to the best of my knowledge and belief. I acknowledge receipt of a variable
annuity and fund prospectuses. By accepting the annuity issued, I agree to any
additions or corrections to this application. I (owner) confirm that any Social
Security/Taxpayer ID Number is correct as it appears on this application.
Annuitant's Signature______________________________________(if other than owner)
Owner's Signature_____________________ Joint Owner's Signature_________________
Signed at_____________________________ ______________________________________
City, State Date
Do you, as Agent, have reason to believe the product applied for will replace
existing annuities or insurance? [ ] Yes [ ] No
<TABLE>
<S> <C> <C> <C> <C>
Licensed Agent _____________________ __________________ __________________ __________________
Signature Print Name Agent ID Number % Shares
Licensed Agent _____________________ __________________ __________________ __________________
Signature Print Name Agent ID Number % Shares
[ ] Option 1 [ ] Option 2 [ ] Option 3
_____________________ __________________ ______________________________________
Broker/Dealer Firm Address Select Option
_____________________ __________________
Date Telephone
</TABLE>
--------------------------------------------------------------------------------
OL3140 3 11-00
