Flexible Premium Deferred Variable Annuity
Northbrook Life Insurance Company - [email protected]
P.O. Box 80469, Lincoln, Nebraska 68501, 1-877-801-7157
1. OWNER INFORMATION
Name ______________________________________________________________________
Last First Middle
Address __________________________________________________
Street Apt.#
___________________________________________________________________________
City State Zip
Social Security/Tax ID # _____________________________________
Birth Date __________________________________________ Sex _______
Month Day Year
Phone ( )_____________________
Day
2. JOINT OWNER INFORMATION, If Applicable
Name ______________________________________________________________________
Last First Middle
Address __________________________________________________
Street Apt.#
___________________________________________________________________________
City State Zip
Social Security/Tax ID # _____________________________________
Birth Date __________________________________________ Sex _______
Month Day Year
Phone ( )_____________________
Day
3. ANNUITANT INFORMATION, If Other Than Owner
Name ______________________________________________________________________
Last First Middle
Address __________________________________________________
Street Apt.#
___________________________________________________________________________
City State Zip
Social Security/Tax ID # _____________________________________
Birth Date __________________________________________ Sex _______
Month Day Year
Phone ( )_____________________
Day
4. BENEFICIARY DESIGNATION
Name ___________________________________________________
Last First Middle
Relationship to Owner _______________________________ __________%
Name ___________________________________________________
Last First Middle
Relationship to Owner _______________________________ __________%
Name ___________________________________________________
Last First Middle
Relationship to Owner _______________________________ __________%
Total designation must equal 100%
5. AMOUNT AND ALLOCATION OF PAYMENT
Total Purchase Payment $_____________
Please allocate the above amount in $ or whole %s to the Investment Alternatives
specified below ($ must equal Total Purchase Payment. %'s must total 100%):
Janus Aspen
| | Capital Appreciation __________
| | Worldwide Growth __________
MSDW Universal Funds
| | Value __________
| | Equity Growth __________
| | Mid Cap Value __________
| | Mid Cap Growth __________
| | U.S. Real Estate __________
| | International Magnum __________
| | Emerging Markets Equity __________
| | Global Equity __________
| | Fixed Income __________
| | High Yield __________
| | Technology __________
VanKampen
| | LIT Comstock __________
| | LIT Emerging Growth __________
Strong
| | VIF Growth Fund II __________
| | Opportunity Fund II __________
Scudder
| | International __________
| | VLIF Bond __________
Warburg Pincus
| | Emerging Growth __________
| | Post Venture Capital __________
6. QUALIFIED PLAN
| | No | | Yes (If yes, complete the following)
| | Traditional IRA | | Roth IRA Other _______________
| | Rollover | | Transfer
| | Contribution $______________ Contribution Year_____________
NLR736
<PAGE>
7. WILL THIS ANNUITY REPLACE ANY EXISTING LIFE INSURANCE OR ANNUITY?
| | No | | Yes__________________________________________________
Company, amount, type of policy and policy number and date
Special Instructions___________________________________________________________
===============================================================================
8. SIGNATURES
| | Optional Consent for Electronic Distribution to my E-mail
address:________________________
I (we) hereby consent to the electronic distribution of annuity and fund
prospectuses, statements of additional information, shareholder reports, proxy
statements and prospectus supplements. I understand that I may revoke this
consent at any time, and that absent my revocation, this consent will be valid.
If Northbrook Life Insurance Company ("Northbrook Life") declines this
application, Northbrook will have no liability except to return the purchase
payments. I understand that annuity values and income payments based on the
investment experience of a variable account are variable and are not guaranteed
as to dollar amount.
I have read the above statements and the applicable fraud warning for my state
listed below.
------------------------------------------------------------------------------
Date
--------------------------------- ------------------------------------------
Owner's Signature Joint Owner's Signature (if applicable)
9. FRAUD WARNINGS
The following states require insurance applicants to acknowledge a fraud warning
statement. Please refer to the fraud warning statement for your state as
indicated below.
For applicants in Arizona: Upon your written request we will provide you within
a reasonable period of time, reasonable, factual information regarding the
benefits and provisions of the annuity contract for which you are applying. If
for any reason you are not satisfied with the contract, you may return the
contract within 20 days after you receive it. If the contract you are applying
for is a variable annuity, you will receive an amount equal to the sum of (1)
the difference between the premiums paid and the amounts allocated to any
account under the contract and (2) the Contract Value on the date the returned
contract is received by our company or agent.
F or applicants in Arkansas, Kentucky, Maine, New Mexico, Ohio, and
Pennsylvania: 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
and civil penalties.
For applicants in Colorado: 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 or claimant
with regard to a settlement or award payable from insurance proceeds shall he
reported to the Colorado Division of Insurance within the Department of
Regulatory Agencies.
For applicants in Florida: Any person who knowingly and with intent to injure,
defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a
felony of the third degree.
For applicants in Louisiana: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
For applicants in New Jersey: Any person who includes any false or misleading
information on an application for an insurance policy is subject to criminal and
civil penalties.
