EXHIBIT 5
Form of Application for Variable Annuity Contract
1010-V
Application for OVERTURE MEDLEY! VARIABLE ANNUITY Please print clearly in black
ink. This form will be photocopied.
1 Policyowner
If a Trust, give Trustee, Trust name & Trust date. All correspondence will be
sent to this address.
Full Name
U.S. Citizen
___Yes ___No
Sex M F
___Social Security Number
___Tax I.D. Number |
Date of Birth
Date of Trust
Address
Day Phone
City
State
ZIP
JOINT OWNER (OPTIONAL)
Full Name
U.S. Citizen
___Yes ___No
Sex M F
___Social Security Number
___Tax I.D. Number |
Date of Birth or Trust
Relationship to Owner
Address
Day Phone
City
State
ZIP
2 Annuitant(s) (If other than Owner)
Full Name
U.S. Citizen
___Yes ___No
Sex M F
Social Security Number
Date of Birth
Relationship to Owner
Address
Day Phone
City
State
ZIP
3 Beneficiary
PRIMARY
Full Name
Relationship to Owner
CONTINGENT
Full Name
Relationship to Owner
NOTE FOR ARIZONA RESIDENTS: On written request, AVLIC will provide, within a
reasonable time, reasonable factual information regarding the benefits and
provisions of the policy for which you are applying. After you receive a policy
from AVLIC, if you are not satisfied with it, you may return it to us or the
selling agent within ten days of the date of delivery of the policy. The amount
of the refund will be equal to that permitted by Arizona Insurance Code.
4 Allocation
Whole percentages only, must total 100%.
Funds listed by Advisor/Subadvisor
FIDELITY Service Class 2
______% Equity-Income
______% Growth
______% High Income
______% Overseas
______% Asset Manager
______% Investment Grade Bond
______% Asset Manager: Growth
______% Contrafund
CALVERT / Socially Responsible Funds
______% Balanced
______% Small Cap Growth
______% Mid Cap Growth
______% International Equity
Ameritas Portfolio (Subadvised)
______% Money Market
ALGER / Alger American Fund
______% Balanced
______% Leveraged AllCap
Ameritas Portfolio (Subadvised)
______% Growth
______% Income & Growth
______% Small Capitalization
______% MidCap Growth
MORGAN STANLEY
______% Emerging Markets Equity
______% Global Equity
______% International Magnum
______% U.S. Real Estate
MFS / MFS Trust
______% Utilities
______% Global Governments
______% New Discovery
Ameritas Portfolio (Subadvised)
______% Emerging Growth
______% Research
______% Growth With Income
STATE STREET / Ameritas Portfolio (Subadvised)
______% Index 500
AMERICAN CENTURY
______% VP Income & Growth
BABSON / Ameritas Portfolio (Subadvised)
______% Micro Cap
INVESCO
______% Dynamics
OAKMARK / Ameritas Portfolio (Subadvised)
______% Select
SALOMON BROTHERS
______% Capital
SUMMIT
______% Nasdaq-100 Index
______% Russell 2000 Small Cap Index
______% S&P MidCap 400 Index
THIRD AVENUE
______% Value
AVLIC
______% Fixed Account
100 % TOTAL
5 Premium Payment
All premium checks must be made payable to the Company. Do not make check
payable to the agent or leave the payee blank.
Initial Premium With Application: $____________________
6 Endorsements/Corrections Home Office use only
Changes in the amount, age at issue, classification, plan of insurance or
benefits must be agreed to in writing by me. Any other corrections noted shall
be binding without my written agreement. This section will not be used in MD, PA
or WV.
7 Suitability Information
To be completed only by Registered Representatives of Ameritas Investment Corp.
Complete in Proposed Owner's presence.
Applicants are urged to supply information in order that the agent may make an
informed judgment as to the suitability for a particular purchaser of a variable
annuity. If the Applicant chooses not to do so, the agent must complete the
following items to the best of his/her knowledge.
___Check this box if the information was not provided by the Applicant.
a. Income for the past 12 months $__________
b. Projected income for the next 12 months $__________
c. Tax Bracket _________%
d. Approximate net worth (excluding home) $__________
e. Is the Proposed Owner(s) in good health on the application date?
___ Yes ___ No (If no, explain)
Annuitant(s)? l Yes l No (If no, explain)
f. Owner's Occupation(s)
g. Employer Name and Address
Investment Objectives: Check at least one. Multiple objectives can ranked based
on importance to you. Primary = 1, Secondary = 2, etc.
___Long Term Gain ___Short Term Gain ___Income
___Tax Advantaged ___Safety of Principal
Risk Tolerance: Rank based on your level of risk. Tolerable = 1, least Tolerable
= 4.
___Low Risk ___Moderate Risk ___Speculative Risk ___High Risk
All Registered Representatives must provide their Broker/Dealer with client
information applicable to suitability. (See your Broker/Dealer for details.)
Supervisory Principal's Signature
8 Telephone Authorization
Unless waived, the Policyowner and Representative will have automatic telephone
transfer authorization.
___ I do NOT want telephone transfer authorization. ___ I do NOT give my
Registered Rep transfer authorization.
I hereby authorize and direct AVLIC to make allowable transfers of funds or
reallocation of net premiums among available subaccounts based upon instructions
received by telephone from (a) me, as Policyowner, (b) my Registered
Representative in Section 14, and (c) the person(s) named below. AVLIC will not
be liable for following instructions communicated by telephone that it
reasonably believes to be genuine. AVLIC will employ reasonable procedures,
including requiring the policy number to be stated, tape recording all
instructions, and mailing written confirmations. If AVLIC does not employ
reasonable procedures to confirm that instructions communicated by telephone are
genuine, AVLIC may be liable for any losses due to unauthorized or fraudulent
instructions.
Name per (c) above
Social Security Number
Address
(This is not to be used for Fee Advisor authorization)
I understand: a) all telephone transactions will be recorded; and b) this
authorization will continue in force until the authorization is revoked by
either AVLIC or me. The revocation is effective when received in writing or by
telephone by the other party.
9 Option Riders
Guaranteed Minimum Death Benefit
___Annual step-up
10 Annuity Type
PLAN TYPE
___ Nonqualified
___ 457 Deferred Comp
___ 401(a) Pension/Profit Sharing
___ 401(k) Profit Sharing
___ 408(b) IRA
___ 408(k) SEP-IRA
___ 408(p) SIMPLE IRA
___ 408A ROTH IRA (Regular Contribution)
=== =============================
TYPE OF TRANSFER
___ 1035 Exchange
___ Direct Transfer
___ Direct Rollover
___ Roth Conversion
11 Replacement
Do you have any existing life insurance or annuities?
___ Yes ___ No
Will this annuity replace any existing life insurance or annuity?
___ Yes ___ No
Company __________________________________________________
Policy No. __________________
FOR YOUR PROTECTION, PLEASE READ THE FOLLOWING NOTICE:
In several states, we are required to advise you of the following: Any person
who knowingly and with intent to defraud provides false, incomplete, or
misleading information in an application for insurance, or who knowingly
presents a false or fraudulent claim for payment of a loss or benefit, is guilty
of a crime and may be subject to fines and criminal penalties, including
imprisonment. In addition, insurance benefits may be denied if false information
provided by an applicant is materially related to a claim.
NOTE FOR COLORADO RESIDENTS: It is unlawful to knowingly provide false,
incomplete, or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance, and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false,
incomplete, or misleading facts or information to a policy holder or claimant
for the purpose of defrauding or attempting to defraud the policy holder or
claimant with regard to a settlement or award payable from insurance proceeds
shall be reported to the Colorado Division of Insurance within the Department of
Regulatory Agencies.
NOTE FOR OREGON/VIRGINIA RESIDENTS: Any person who, with intent to defraud or
knowing that he is facilitating a fraud against insurer, submits an application
or files a claim containing a false or deceptive statement may have violated
state law.
NOTE FOR NEW JERSEY RESIDENTS: Any person who includes any false or misleading
information on an application for an insurance policy is subject to criminal and
civil penalties.
NOTE FOR PENNSYLVANIA RESIDENTS: Any person who knowingly and with intent to
defraud any insurance company or other person files an application for insurance
or 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 or civil penalties.
IMPORTANT: MAKE ALL CHECKS PAYABLE ONLY TO AMERITAS VARIABLE LIFE INSURANCE
COMPANY
1. I (We) hereby represent to the best of my (our) knowledge and belief that
each of the statements and answers contained above are full, complete, and true.
2. I (We) certify that the Social Security or taxpayer identification number
shown above is correct.
3. I (We) understand that policy values may increase or decrease according to
the investment experience of the Separate Account and that the dollar amounts
are not guaranteed and this policy meets my investment objectives and
anticipated financial needs.
4. The Annuity Date is the later of five policy years or age 85 unless otherwise
requested.
5. I (We) have been given a current Prospectus for this variable annuity which
explains insurance-related charges.
6. If you are purchasing this policy for use in a tax-qualified plan, please
acknowledge the following: I have been informed and understand that a tax-
deferred accrual feature is provided through my tax-qualified plan and this
annuity does not provide any additional tax-deferral benefit. In addition, I am
also acknowledging that I am purchasing this annuity policy for use in a tax-
qualified plan because of its features and/or benefits other than tax- deferral
(such as the lifetime income option, available death benefit and/or maximum
guarantee fees).
Dated and Signed at
CITY
STATE
on this Date
Signature of Owner
Title of Officer or Trustee(s)
Signature of Joint Owner
Title of Officer or Trustee(s)
Signature of Annuitant if other than Owner
Signature of Joint Annuitant
REGISTERED REPRESENTATIVE STATEMENT: (Must check appropriate box.) To your
knowledge, does the applicant have existing life insurance or annuity policies?
___ Yes ___ No. Do you have any knowledge or reason to believe that replacement
of existing insurance or annuity coverage may be involved? l Yes l No (If yes,
give details in Section 11 and complete any state required replacement forms.) I
certify that: (1) the information provided by the owner has been accurately
recorded; (2) a current prospectus was delivered; and (3) I have reasonable
grounds to believe the purchase of the policy is suitable for the owner.
Signature of Registered Representative/Agent
Print Name Here
12 Policy Delivery
If not completed, policy will be sent to owner.
Send to: ___ Owner ___ Representative
13 Representative/Dealer Information
Schedule Type: ___ A ___ B ___ C (Default is Schedule B.)
Representative Name (please print)
Code
Representative Name (please print)
Code
Agency/Broker Dealer (please print)
Code
14 Questions
If you have questions when completing this application or on other supporting
documents, please call 1-800-634-8353. If Ameritas has questions concerning this
application, whom should we call at your office?
Name (please print)
Phone
Fax
E-mail
15 Mail Application to:
Ameritas Variable Life Insurance Company
P.O. Box 82550
Lincoln, NE 68501-2550 FAX#: 402-467-6153
Overnight Deliveries:
Ameritas Variable Life Insurance Company
5900 "O" Street
Lincoln, NE 68510
UVA Ed. 1-01
