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SAFECO Life Insurance Company
Spinnaker(R)Advisor Variable Annuity 5069 154th Place NE
[SAFECO Logo] Individual Deferred Variable Annuity Application Redmond, WA 98052-9669
Telephone 1-877-472-3326
TTY/TDD 1-800-833-6388
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MINIMUM PURCHASE PAYMENT AMOUNTS
Initial Purchase Payment: $10,000
Minimum Allocations to the Fixed Account Options:
Dollar Cost Averaging (DCA) Fixed Account Option: $5,000
Guaranteed Interest Period Fixed Account Option: $1,000 for each selected Guaranteed Period
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1. Owner
Information Name_____________________________________________________________________________________________________
First Middle Last
Mailing Address__________________________________________________________________________________________
Street City State Zip Code
Telephone (_____)________________________ Soc. Sec. #_____________________ Date of Birth_________________
Joint Owner Mo. Day Yr.
(Non-Qualified Only)
Name_____________________________________________________________________________________________________
First Middle Last
Mailing Address__________________________________________________________________________________________
Street City State Zip Code
Telephone (_____)________________________ Soc. Sec. #_____________________ Date of Birth_________________
Mo. Day Yr.
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2. Annuitant
Information Name__________________________________________________________________________ [] Male [] Female
First Middle Last
(Non-Qualified
Only)
Mailing Address__________________________________________________________________________________________
Street City State Zip Code
Telephone (_____)________________________ Soc. Sec. #_____________________ Date of Birth_________________
Mo. Day Yr.
If no Annuitant is specified, the Owner will be the Annuitant.
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3. Type of Annuity []TSA [] Deferral TSA []Transfer from another TSA
[] Transfer TSA was an Annuity under IRC 403(b)
[] IRA [] Individual Retirement Annuity (IRA)
[] Contribution for calendar year_________ to a [] Regular IRA or []Roth IRA
[] Rollover* from a []Regular IRA or [] Roth IRA
[] Transfer* from a [] Regular IRA or [] Roth IRA
The taxable year for which I first made a Roth IRA contribution was ________.
[] Convert my Regular IRA by rollover or transfer to a Roth IRA.
[] Rollover* from a Qualified Retirement Plan or TSA
[] Simplified Employee Pension (SEP) IRA Plan
[] Salary Reduction (SARSEP). Only available if plan established prior to 1997.
[] Savings Incentive Match Plan for Employees (SIMPLE) IRA
[] Rollover* from a SIMPLE IRA Original date of SIMPLE IRA ___/___/_____
[] Non-Qualified Annuity [] 1035 Exchange.*
* Must complete Form LP-1185, Rollover, Transfer, and/or Exchange Request.
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4. Transfer & ROLLOVER, TRANSFER, AND EXCHANGES
Replacement Annuity Will the annuity applied for here replace any
annuity or life insurance from this or any other
company?
[] Yes [] No If yes, give policy number and full company name: Policy #:________________
Company Name:____________________________________________________________________________________________
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LPC-1161 3/00 R Registered trademark of Safeco Corporation
R Spinnaker is a registered trademark of SAFECO Life Insurance Company
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5. Beneficiary
Primary: Name ______________________________________________________________ Percentage________%
(Please attach a First Middle Last
signed and dated Mailing Address________________________________________________________________________________________
listing of any Street City State Zip Code
additional names.) Soc. Sec. #______________________________ Date of Birth______________________ [] Male [] Female
Mo. Day Yr.
Relationship to Owner__________________________________________________________________________________
CONSENT OF SPOUSE REQUIRED FOR ERISA PLAN PARTICIPANT NAMING A NON-SPOUSE PRIMARY
BENEFICIARY: I consent to the above designation of
Beneficiary. I understand that if anyone other than
me is designated as Primary Beneficiary on this
form, I am waiving my right to receive benefits
under the plan when my spouse dies.
Signature of Spouse________________________________________________________________Date _______________
Mo. Day Yr.
[] I am not married.
[] PRIMARY
[] CONTINGENT: Name____________________________________________________________ Percentage_______%
First Middle Last
Mailing Address_______________________________________________________________________________________
Street City State Zip Code
Soc. Sec. #______________________________ Date of Birth_______________________ [] Male [] Female
Mo. Day Yr.
Relationship to Owner__________________________________________________________________________________
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6. Investment Initial Subsequent Investment Option
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Instructions _______% _______% SAFECO RST Bond
_______% _______% SAFECO RST Equity
Choose one or more of _______% _______% SAFECO RST Growth Opportunities
the following. Whole _______% _______% SAFECO RST Money Market
percentages only. _______% _______% SAFECO RST Northwest
_______% _______% SAFECO RST Small Company Value
Total of all _______% _______% AIM V.I. Aggressive Growth
percentages must _______% _______% AIM V.I. Growth
equal 100%. _______% _______% American Century VP Balanced
_______% _______% American Century VP International
_______% _______% Dreyfus IP MidCap Stock
_______% _______% Dreyfus IP Technology Growth
_______% _______% The Dreyfus Socially Responsible Growth Fund, Inc.
_______% _______% Dreyfus VIF Appreciation
_______% _______% Dreyfus VIF Quality Bond
_______% _______% Federated High Income Bond Fund II
_______% _______% Federated Utility Fund II
_______% _______% Fidelity VIP Growth
_______% _______% Fidelity VIP III Growth & Income
_______% _______% Fidelity VIP III Growth Opportunities
_______% _______% Franklin Small Cap Fund - Class 2
_______% _______% Franklin U.S. Government Fund - Class 2
_______% _______% INVESCO VIF-Real Estate Opportunity Fund
_______% _______% J.P. Morgan U.S. Disciplined Equity
_______% _______% Scudder VLIF Balanced
_______% _______% Scudder VLIF International
_______% _______% Templeton Developing Markets Securities Fund - Class 2
_______% N/A SAFECO DCA Fixed Account Option [] 6 months or [] 12 months
(Please allocate DCA percentages in Section 8)
SAFECO Guaranteed Interest Period Fixed Account Option
_______% _______% 1-Year Guaranteed Period
_______% _______% 3-Year Guaranteed Period
_______% _______% 5-Year Guaranteed Period
_______% _______% ___-Year Guaranteed Period (as approved by
SAFECO Life. Contact your Registered
Representative or SAFECO Life
for the availability
of longer Guaranteed Periods.)
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(Continued)
Investment Instructions Purchase Payments to the SAFECO Fixed Account Options will be allocated immediately upon receipt.
Purchase Payments to the variable Portfolios may be invested in the SAFECO RST Money Market Portfolio
until the expiration of 15 days from the date the first Purchase Payment is received, and then will
be invested according to your investment instructions.
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7. Systematic Investing I would like to make regular Purchase Payments from my checking or savings
account. I have completed Form LPS-5318 and am sending it in with this application.
(Not available for TSA or 457 Plans.)
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8. Scheduled Transfers I have read the information in the Prospectus about the following scheduled transfers and would like to
elect:
1. Dollar Cost Averaging: I elect to transfer $_________ (minimum $50) or _______% from the
[]________________________________ Portfolio or [] Dollar Cost Averaging Fixed Account
Option [] monthly [] quarterly to the Portfolios listed below.
2. Appreciation Sweep ($10,000 minimum account balance required): I elect to have the
appreciation of the Money Market Portfolio transferred [] monthly [] quarterly []
annually to the Portfolios listed below.
3. Portfolio Rebalancing ($10,000 minimum account balance required): I elect to rebalance my
Portfolios [] quarterly [] semiannually [] annually.
____% SAFECO RST Bond ____% Dreyfus VIF Quality Bond
____% SAFECO RST Equity ____% Federated High Income Bond Fund II
____% SAFECO RST Growth Opportunities ____% Federated Utility Fund II
____% SAFECO RST Money Market ____% Fidelity VIP Growth
____% SAFECO RST Northwest ____% Fidelity VIP III Growth & Income
____% SAFECO RST Small Company Value ____% Fidelity VIP III Growth Opportunities
____% AIM V.I. Aggressive Growth ____% Franklin Small Cap Fund - Class 2
____% AIM V.I. Growth ____% Franklin U.S. Government Fund -
____% American Century VP Balanced Class 2
____% American Century VP International ____% INVESCO VIF-Real Estate Opportunity Fund
____% Dreyfus IP MidCap Stock ____% J.P. Morgan U.S. Disciplined Equity
____% Dreyfus IP Technology Growth ____% Scudder VLIF Balanced
____% The Dreyfus Socially Responsible ____% Scudder VLIF International
Growth Fund, Inc. ____% Templeton Developing Markets
____% Dreyfus VIF Appreciation Securities Fund - Class 2
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9. Telephone Transfer I, __________________________________________ , hereby authorize SAFECO Life Insurance Company (SAFECO)
Authorization to accept and act on telephone instructions from me or any person(s) listed below regarding the transfer
of funds between, or change in the percentage of my allocations among, portfolios of my variable
annuity contract. This authorization will remain in effect until SAFECO receives written revocation
from me.
SAFECO will employ reasonable procedures to confirm that instructions communicated by telephone are
genuine. SAFECO reserves the right to refuse telephone instructions from any caller when unable
to confirm to SAFECO's satisfaction that the caller is authorized to give those instructions.
To transfer by telephone, call SAFECO at 1-877-4SAFECO (472-3326). All telephone transfer
calls will be recorded. You or your authorized third party will be required to provide the
identification information listed below. Written confirmation of transfer transaction(s) will be
mailed to you.
Unless otherwise indicated, this form does not permit anyone else to exercise discretionary
authority to effect transactions on my behalf without obtaining my prior authorization. If you
are unsure if you have this authority, please consult your broker/dealer.
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Print or type full name of Authorized Third Party
IDENTIFICATION INFORMATION:
My mother's maiden name is:___________________________________________ Account #:______________________
(if available)
___________________________________________________________________________ ________________________
Signature of Owner Date
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10. Statement of Owner(s) Have you received a current Prospectus? [] Yes [] No
FRAUD WARNING: Any person who knowingly and with
intent to defraud any insurance company or other
person files an application of insurance 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.
I declare that the statements and answers on this
application are full, complete, and true, to the best
of my knowledge and belief, and shall form a part of
the annuity contract issued hereon. I understand and
agree that any fees or taxes will be deducted from my
contract value or purchase payment, as applicable.
I understand that when contract values and annuity
payments are based on investment performance of the
Separate Account, the dollar amounts cannot be
predicted or guaranteed. I also understand that
withdrawals from the Guaranteed Period Fixed Account
Option before the end of the Guarantee Period will be
subject to a market value adjustment that will
increase or decrease the cash surrender benefit.
Variable annuity contracts should be purchased for
long-term retirement purposes.
______________________________________________________________ _________________________________________
Signature of Owner Signed in City, State
______________________________________________________________ _________________________________________
Signature of Joint Owner (if applicable) Date
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11. TSA Information Employer Name _________________________________________________________________________________________
Address_______________________________________________________________________________________________
Street City State Zip Code
Please verify that the TSA Plan Information Sheet
is on file with the SAFECO Life Home Office. This
application cannot be processed without
verification of Employer's eligibility to sponsor a
403(b) Plan.
Plans covered by ERISA:
This employee has satisfied all eligibility
requirements to receive contributions under our
plan. Furthermore, Joint & Survivor Annuity option
disclaimers (if required by plan) are on file with
the Plan Administrator.
______________________________________________________________ ______________________________________
Plan Administrator Signature Date
Contribution Frequency:
[] Annual (01) [] Bi-Weekly (26) Deductions will begin the month of:
[] Quarterly (04) [] Weekly (52) ______________________________________________
[] Monthly (12) [] 10 Pay Periods Month(s) to exclude:
[] Semi-Monthly (24) _______________________________________________
[] Other: ________________________________________ Contribution per pay frequency:
$____________________________________________
Source of Contribution: Anticipated annual contributions:
[] Employee Salary Reduction $__________________________________________
[] Employer (Amount must be provided)
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12. Registered To the best of my knowledge, the annuity applied for here []
Representative does [] does not replace any life insurance or annuity in
Information this or any other company. I hereby certify that I witnessed the
signature(s) above and that the answers to the questions above
are true to the best of my knowledge and belief.
______________________________________________________________ ______________________________________
Registered Representative's Name Stat # %
______________________________________________________________ ______________________________________
Registered Representative's Name Stat # %
______________________________________________________________ ______________________________________
Agency State/Location ID #
______________________________________________________________ ( )_____________________
________________
Registered Representative's Signature Telephone Number
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