<PAGE>
Exhibit 5(i)
<TABLE>
<CAPTION>
[LOGO OF NEW ENGLAND FINANCIAL] ---------------------------
For Company Use Only
No.________________
----------------------------
Application to New England Life Insurance Company (NELICO),
Boston, Massachusetts for a Variable Annuity
------------------------------------------------------------------------------------------------------------------------------------
<S> <C>
1. Annuitant
_________________________________________________________________ Social Security Number/ [_][_][_] - [_][_] - [_][_][_][_]
Name_____________________________________________________________ Tax Identification Number
_________________________________________________________________ Date of Birth [_][_]/[_][_]/[_][_]
Street Address
_________________________________________________________________ Gender: |_| male |_| female
City State Zip
____________________________________________________________________________________________________________________________________
3. Owner* (if different from annuitant) 4. Joint Owner
_________________________________________________________________ ____________________________________________________________
Name Name
_________________________________________________________________ ____________________________________________________________
Street Address Street Address
_________________________________________________________________ ____________________________________________________________
City State Zip City State Zip
Social Security Number/ [_][_][_] - [_][_] - [_][_][_][_] Social Security Number/ [_][_][_] - [_][_] - [_][_][_][_]
Tax Identification Number Tax Identification Number
Date of Birth/Date of Trust [_][_]/[_][_]/[_][_] Date of Birth [_][_]/[_][_]/[_][_]
Gender: |_| male |_| female Gender: |_| male |_| female
*If owner is a trust, please complete the Trustee Certification
------------------------------------------------------------------------------------------------------------------------------------
5. Beneficiary
Primary* Secondary
_________________________________________________________________ ____________________________________________________________
Name Name
Social Security Number/ [_][_][_] - [_][_] - [_][_][_][_] Social Security Number/ [_][_][_] - [_][_] - [_][_][_][_]
Tax Identification Number Tax Identification Number
Relationship _________________________________________ Relationship________________________________________________
*If owner is a trust, the trust must be the beneficiary
------------------------------------------------------------------------------------------------------------------------------------
6. Type of Contract
|_| IRA |_| Roth IRA |_| SEP IRA |_| Non-qualified
|_| Qualified Plan (type_________) |_| SIMPLE IRA |_| TSA Transfer |_| Other _________
------------------------------------------------------------------------------------------------------------------------------------
7. Purchase Payments
Initial Purchase Payment $______________________________________ and/or Transfers: $ _______________________
Method of Payment: |_| Check |_| Wire |_| Draft (if new, please complete MSA or ACH application)
Tax Year _________
A) Bill $ ________________ |_| Monthly |_| Quarterly |_| Semi-Annually |_| Annually
------------------------------------------------------------------------------------------------------------------------------------
8. Replacements
Do you have any existing life policies or annuity contracts? |_| Yes |_| No
Is this annuity being purchased to replace existing insurance and annuity policy(s)? |_| Yes |_| No
If "Yes", applicable disclosure and replacement forms must be attached.
------------------------------------------------------------------------------------------------------------------------------------
</TABLE>
<PAGE>
<TABLE>
<CAPTION>
<S> <C>
------------------------------------------------------------------------------------------------------------------------------------
9. Special Requests
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
10. Optional Riders Administrative Use Only:
Death Benefit Rider Options Additional Amendments
|_| Annual Step Up
|_|Greater of Annual Step Up and 5% Annual Increase
|_| [Guaranteed Minimum Income Benefit Rider]
|_| [Earnings Preservation Benefit Rider]
------------------------------------------------------------------------------------------------------------------------------------
11. Owner(s) Signatures
Notice for applicant
For Florida Residents Only: 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 New Jersey Residents Only: Any person who includes any false or misleading information on an application for an insurance policy
is subject to criminal and civil penalties.
For Arkansas, Kentucky, Maine, Louisiana, New Mexico, Ohio, Pennsylvania, and Washington, D.C. Residents Only: Any person who
knowingly and with intent to defraud any insurance company or other person files an application or submits a 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.
ANNUITY PAYMENTS OR SURRENDER VALUES, WHEN BASED UPON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT
GUARANTEED AS TO A FIXED DOLLAR AMOUNT.
General. To the best of my knowledge and belief, the answers recorded are true and complete. My agreement in writing is required to
any change made by the Company as to information in the Application.
When the Contract Takes Effect. The contract will take effect as of the latest of: (a) the date of the Application; (b) the date the
first purchase payment and first premium for any riders are paid; and (c) any date of issue that is requested; provided that this
Application can be approved by the Company as submitted.
Owner's Social Security or Employer Identification Number:______________________
|_| I AM |_| I AM NOT subject to backup withholding under Section 3406(a)(1)(C) of the Internal Revenue Code. Under penalties of
perjury, I certify that the information provided in this section is true, correct and complete.
Signed at __________________________________ On_______________________ ________________________________________________
City, State (month/day/year) Owner Signature
________________________________________________
Joint Owner Signature
------------------------------------------------------------------------------------------------------------------------------------
12. Registered Representative Signature(s)
Responses completed by Registered Representative
A. Do you have reason to believe that replacement or change of any existing insurance or annuity may be involved? |_| Yes |_| No
B. Does Owner (Annuitant if non-natural person) appear to be in good health and mentally competent? (if no, give details in
separate memo) |_| Yes |_| No
Registered Representative Name_________________________________________ State License Identification Number____________________
______________________________________________________ _____________________
Registered Representative Signature (month/day/year)
Accepted at the Company at the Administrative Office by: _______________________________ _______________
Principal Signature (month/day/year)
------------------------------------------------------------------------------------------------------------------------------------
</TABLE>
