MORGAN STANLEY DEAN WITTER VA3 ASSETMANAGER
FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY
ISSUED BY: NORTHBROOK LIFE INSURANCE COMPANY, NORTHBROOK, ILLINOIS
PO Box 94040, Palatine, IL 60094-4040 Telephone: 1-800-654-2397
Overnight Address: 3100 Sanders Rd., M4A, Northbrook, IL 60062
OW N E R(S) Name _____________________________ (_)M ( )F Birthdate __/__/___
Address______________________________Soc. Sec. no. ____/___/____
Name _____________________________ (_)M ( )F Birthdate __/__/___
Address______________________________Soc. Sec. no. ____/___/____
AN N U I TA N T
Leave blank if Annuitant is the same as sole Owner; otherwise complete.
Name _____________________________ (_)M ( )F Birthdate __/__/___
Address______________________________Soc. Sec. no. ____/___/____
Relationship to Owner___________________________________________
BE N E F I C I A R Y(I E S)
Name _____________________________ Relationship to Owner _______
Name _____________________________ Relationship to Owner ______
PU R C H A S E PAY M E N T/ P L A N OP T I O N S
Total Purchase Payment $________________________________________________________
VARIABLE PORTFOLIO SECTION
AIM Variable Ins. Funds
(_) Aggressive Growth
(_) Blue Chip __% MSDW Universal Funds
(_) Capital Appreciation __% (_) Equity Growth __%
(_) Growth __% (_) International Magnum __%
(_) Value __% (_) Emerging Markets Equity __%
(_) U.S. Real Estate __%
Alliance Variable Product Series Funds (_) Mid-Cap Value __%
(_) Premier Growth __%
(_) Growth __% Putnam Variable Trust
(_) Growth & Income __% (_) International Growth __%
(_) International New Opportunities __%
(_) Growth & Income __%
(_) New Opportunities __%
(_) OTC & Emerging Growth __%
MSDW Variable Investment Series (_) Voyager __%
(_) Money Market __%
(_) Quality Income Plus __% Van Kampen Life Investment Trust
(_) High Yield __% (_) Emerging Growth __%
(_) Utilities __%
(_) Income Builder __% Fixed Account (if available)
(_) Dividend Growth __% (_) DCA Fixed Account __%
(_) Capital Growth __% (_) Fixed __%
(_) Global Div. Growth __% (_) _____________________ __%
(_) European Growth __% Total 100%
(_) Pacific Growth __%
(_) Equity __% Plan Options (Choose one from options
(_) S & P 500 Index __% available in your state. If none is
(_) Competitive Edge __% selected, base policy will apply):
(_) Strategist __%
(_) Agressive Equity __% (_) Performance Death Benefit Option
(_) Short-Term Bond __% (Highest Anniversary Value); or
(_) Performance Income Benefit 2 Option
(GuMBI); or
(_) Performance Benefit Combination 2
Option
(_) Death Benefit Combination Option
Best of the Best)
RE P L A C E M E N T Will this annuity replace or change any
IN F O R M AT I O N existing annuity or life insurance? (_)Yes (_)No
(If Yes, complete the following.)
Company_______________________Policy No. ______
Cost basis ammount ___________Policy Date _____
TA X QU A L I F I E D PL A N (_)Yes (_)No (If Yes, complete the following.)
(_) Traditional IRA (_) Roth IRA (_)SEP (_)Other
(_) Rollover (_)4-1(a)(pension)
(_) Transfer (_)403(b)(TSA)
(_) Contribution $_______ Contribution Year ____
SP E C I A L IN S T R U C T I O N S _______________________________________
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NLR741 41360
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MORGAN STANLEY DEAN WITTER VA3 ASSETMANAGER FLEXIBLE PREMIUM DEFERRED
VARIABLE ANNUITY ISSUED BY: NORTHBROOK LIFE INSURANCE COMPANY, NORTHBROOK,
ILLINOIS PO Box 94040, Palatine, IL 60094-4040 (_) Telephone:
1-800-654-2397 (_)Overnight Address: 3100 Sanders Rd., M4A, Northbrook, IL
The following states require insurance applicants to acknowledge a fraud
warning/disclosure statement. Please refer to the fraud warning/disclosure
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 twenty 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 (i) the difference between the premiums paid and
the amounts allocated to any account under the contract and (ii) the
contract Value on the date the returned contract is received by our company
or our agent.
FOR APPLICANTS IN ARKANSAS, KENTUCKY, MAINE, NEW MEXICO, OHIO, OREGON &
PENNSYLVANA: 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 may be 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 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.
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.
FOR APPLICANTS IN WASHINGTON, D.C.: WARNING: It is a crime to provide false
or misleading information to an insurer for the purpose of defrauding the
insurer or any other person. Penalties include imprisonment and/or fines.
In addition, an insurer may deny insurance benefits if false information
materially related to a claim was provided by the applicant.
SIGNATURE(S)
(contract applications and certificate enrollments are referred to as
applications.)
A copy of this application signed by the Representative will be the receipt for
the first purchase payment. If Northbrook Life Insurance Company ("Northbrook
Life") declines this application, Northbrook Life will have no liability except
to return the first purchase payment.
I have read the above statements and represent that they are complete and true
to the best of my knowledge and belief. I agree that this application shall be a
part of the annuity issued by Northbrook Life. By accepting the annuity issued,
I agree to any additions or corrections to this application. Northbrook Life
will obtain written agreement from me for any change in the benefits, type of
plan, or birthdates.
I understand that annuity values and income payments based on the investment
experience of a separate account are variable and not guaranteed as to dollar
amount. I acknowledge receipt of the current prospectus for the Flexible Premium
Deferred Variable Annuity.
Signed at____________________________________________Date_____/_____/_____
City State
Owner(s)__________________________________________________________________
Annuitant_________________________________________________________________
FINANCIAL ADVISOR USE ONLY
Will the annuity applied for replace or change any existing annuity or
life insurance? (_) Yes (_) No
FA Name (Please print)_______________________ Phone No.(___)___-______
FA Signature_________________________________ Branch/FA No. __________
FL License No. _____________________________
