EXHIBIT 5
FORM OF APPLICATION
<PAGE>
<TABLE>
<CAPTION>
<S> <C>
[LOGO] PHOENIX PHL VARIABLE INSURANCE COMPANY
REGULAR MAIL: Phoenix Variable Products Mail Operation
PO Box 8027, Boston MA 02266-8027 PHOENIX INCOME ADVANTAGE(SM)
EXPRESS MAIL: PHL Variable Insurance Company IMMEDIATE ANNUITY APPLICATION
66 Brooks Drive, Braintree MA 02184
</TABLE>
--------------------------------------------------------------------------------
1. ANNUITANT
--------------------------------------------------------------------------------
Name (Print as desired in contract)
--------------------------------------------------------------------------------
Social Security Number _ _ _ - _ _ - _ _ _ _
--------------------------------------------------------------------------------
Date of Birth Sex
[ ] Male
[ ] Female
--------------------------------------------------------------------------------
Address (Number and Street)
--------------------------------------------------------------------------------
City State ZIP Code
--------------------------------------------------------------------------------
Phone _ _ _ / _ _ _ - _ _ _ _
--------------------------------------------------------------------------------
2. JOINT ANNUITANT - (Payment Options C and D ONLY)
--------------------------------------------------------------------------------
Name
--------------------------------------------------------------------------------
Social Security Number _ _ _ - _ _ - _ _ _ _
--------------------------------------------------------------------------------
Date of Birth Sex
[ ] Male
[ ] Female
--------------------------------------------------------------------------------
Address (Number and Street)
--------------------------------------------------------------------------------
City State ZIP Code
--------------------------------------------------------------------------------
Phone _ _ _ / _ _ _ - _ _ _ _
--------------------------------------------------------------------------------
3. OWNER
--------------------------------------------------------------------------------
Name (Print as desired in contract)
--------------------------------------------------------------------------------
Social Security Number/
Federal I.D. _ _ _ - _ _ - _ _ _ _
--------------------------------------------------------------------------------
Date of Birth Sex
[ ] Male
[ ] Female
--------------------------------------------------------------------------------
Address (Number and Street)
--------------------------------------------------------------------------------
City State ZIP Code
--------------------------------------------------------------------------------
Phone _ _ _ / _ _ _ - _ _ _ _
--------------------------------------------------------------------------------
4. JOINT OWNER - (If any)
--------------------------------------------------------------------------------
Name
--------------------------------------------------------------------------------
Social Security Number/
Federal I.D. _ _ _ - _ _ - _ _ _ _
--------------------------------------------------------------------------------
Date of Birth Relationship to Owner Sex
[ ] Male
[ ] Female
--------------------------------------------------------------------------------
5. PROOF OF AGE - (Required for Life and Joint Life Options)
--------------------------------------------------------------------------------
[ ] Annuitant [ ] Joint Annuitant
(Submit copy of Birth Certificate or Driver's License)
--------------------------------------------------------------------------------
6. BENEFICIARY DESIGNATION
--------------------------------------------------------------------------------
Name
--------------------------------------------------------------------------------
Relationship
%
--------------------------------------------------------------------------------
Name
--------------------------------------------------------------------------------
Relationship
%
--------------------------------------------------------------------------------
Name
--------------------------------------------------------------------------------
Relationship
%
--------------------------------------------------------------------------------
7. PAYMENT OPTIONS
--------------------------------------------------------------------------------
[ ] Option A - Single Life Annuity
[ ] Option B - Single Life Annuity with Period Certain
[ ] 10 yr Certain [ ] 15 yr Certain [ ] 20 yr Certain
[ ] Option C - Joint Survivor Life Annuity
Percent to Survivor [ ] 50% [ ] 100%
[ ] Option D - Joint Survivor Life Annuity with Period Certain
[ ] 10 yr Certain [ ] 15 yr Certain [ ] 20 yr Certain
Percent to Survivor [ ] 50% [ ] 100%
[ ] Option E - Annuity for a Specified Period
____________ Number of years (5 to 30)
[ ] Option F - Life Expectancy Annuity
[ ] Option G - Unit Refund Life Annuity
--------------------------------------------------------------------------------
8. GUARANTEED MINIMUM PAYMENT RIDER - (Not available in all states)
--------------------------------------------------------------------------------
[ ] Yes, I elect this optional rider. Election of this rider restricts your
selection of Payment Options, AIR and Premium Allocation.
--------------------------------------------------------------------------------
9. ASSUMED INTEREST RATE (AIR) - (Required if Variable Annuity Payments are
elected)
--------------------------------------------------------------------------------
[ ] 3% or [ ] 6%
Used to establish the initial Variable Annuity Payment and cannot be changed
once selected
--------------------------------------------------------------------------------
10. PLAN TYPE - (Select one)
--------------------------------------------------------------------------------
[ ] Nonqualified [ ] 1035 Exchange $________________
Cost Basis
[ ] Transfer/Rollover IRA
[ ] Traditional [ ] SEP [ ] Simple [ ] Roth
[ ] 403(b) Rollover [ ] 401(a) Qualified Plan
[ ] 457 Deferred Compensation
Estimated Transfer Amount $________________
--------------------------------------------------------------------------------
OL3140 1 11-00
<PAGE>
--------------------------------------------------------------------------------
11. PREMIUM WITH APPLICATION
--------------------------------------------------------------------------------
Premium with Application $_______________
Make Premium Payment check payable to "PHOENIX".
PREMIUM ALLOCATION
Fixed Income Allocation ______%
Variable Payment Allocation ______%
100%
Amount allocated to Variable Annuity Payments should be invested as follows:
_____ % Phoenix-Aberdeen International
_____ % Phoenix-Aberdeen New Asia
_____ % Phoenix-Bankers Trust Dow 30
_____ % Phoenix-Bankers Trust Nasdaq-100 Index(R)
_____ % Phoenix-Duff & Phelps Real Estate Securities
_____ % Phoenix-Engemann Capital Growth
_____ % Phoenix-Engemann Nifty-Fifty
_____ % Phoenix-Engemann Small & Mid-Cap Growth
_____ % Phoenix-Federated US Govt Bond
_____ % Phoenix-Goodwin Money Market
_____ % Phoenix-Goodwin Multi-Sector Fixed Income
_____ % Phoenix-Hollister Value Equity
_____ % Phoenix-J.P. Morgan Research Enhanced Index
_____ % Phoenix-Janus Equity Income
_____ % Phoenix-Janus Flexible Income
_____ % Phoenix-Janus Growth
_____ % Phoenix-Morgan Stanley Focus Equity
_____ % Phoenix-Oakhurst Balanced
_____ % Phoenix-Oakhurst Growth and Income
_____ % Phoenix-Oakhurst Strategic Allocation
_____ % Phoenix-Sanford Bernstein Global Value
_____ % Phoenix-Sanford Bernstein Mid-Cap Value
_____ % Phoenix-Sanford Bernstein Small-Cap Value
_____ % Phoenix-Seneca Mid-Cap Growth
_____ % Phoenix-Seneca Strategic Theme
_____ % Alger American Leveraged AllCap Portfolio
_____ % EAFE(R) Equity Index Fund
_____ % Federated Fund for US Government Securities II
_____ % Federated High Income Bond Fund II
_____ % Fidelity VIP Contrafund(R) Portfolio
_____ % Fidelity VIP Growth Opportunities Portfolio
_____ % Fidelity VIP Growth Portfolio
_____ % Technology Portfolio
_____ % Mutual Shares Securities Fund - Class 2
_____ % Templeton Asset Strategy Fund - Class 2
_____ % Templeton Developing Markets Securities Fund - Class 2
_____ % Templeton Growth Securities Fund - Class 2
_____ % Templeton International Securities Fund- Class 2
_____ % Wanger Foreign Forty
_____ % Wanger International Small Cap
_____ % Wanger Twenty
_____ % Wanger US Small Cap
_____ TOTAL
--------------------------------------------------------------------------------
12. PAYMENT FREQUENCY
--------------------------------------------------------------------------------
[ ] Monthly [ ] Level Monthly [ ] Quarterly
[ ] Semi-Annually [ ] Annual
[ ] Annuity Direct Deposit (complete separate Bank Authorization form)
NOTE: Your first Annuity Payment will be one month following your Contract Date,
regardless of the mode selected.
--------------------------------------------------------------------------------
13. REPLACEMENT
--------------------------------------------------------------------------------
Will this annuity replace any existing life insurance or annuity?
[ ] Yes [ ] No Details: ___________________________________________________
Company ________________________________________________________________________
Policy No. _____________________________________________________________________
--------------------------------------------------------------------------------
14. SPECIAL REMARKS
--------------------------------------------------------------------------------
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
--------------------------------------------------------------------------------
15. TAX WITHHOLDING INFORMATION
--------------------------------------------------------------------------------
Your payments are subject to income tax withholding unless you elect not to have
withholding apply. Withholding applies only to the portion of your payment that
is subject to federal income tax. You may elect not to have withholding apply by
checking the box below. Your election will remain in effect until revoked. If
you elect no withholding, or if you do not have enough tax withheld from your
distribution, you may have to pay an estimated tax. If your withholding and
estimated tax payments are insufficient, you may be penalized under the
estimated tax rules. You may revoke your election at any time. Other federal or
state mandatory withholding rules may apply to certain distributions.
FEDERAL INCOME TAX WITHHOLDING (select one)
[ ] NO, I/we do not want to have Federal Income Tax withheld. OR
[ ] YES, I/we want Federal Income Tax withheld.
MARITAL STATUS
[ ] Single [ ] Married [ ] Married, but withhold at higher Single rate.
o Number of allowances __________
o I want an additional amount withheld from each Annuity Payment $__________
--------------------------------------------------------------------------------
16. PAYEE INFORMATION - (If left blank, Annuitant will be considered payee)
--------------------------------------------------------------------------------
1. Name (Print First, MI, Last)
%
--------------------------------------------------------------------------------
Address (Number and Street)
--------------------------------------------------------------------------------
City State ZIP Code
--------------------------------------------------------------------------------
2. Name (Print First, MI, Last)
--------------------------------------------------------------------------------
Address (Number and Street)
%
--------------------------------------------------------------------------------
City State ZIP Code
--------------------------------------------------------------------------------
OL3140 2 11-00
<PAGE>
--------------------------------------------------------------------------------
TELEPHONE / ELECTRONIC AUTHORIZATION
--------------------------------------------------------------------------------
I will receive this privilege automatically. By checking "Yes," I am authorizing
and directing Phoenix to act on telephone or electronic instructions from my
licensed agent who can furnish proper identification. Phoenix will use
reasonable procedures to confirm that these instructions are authorized and
genuine. As long as these procedures are followed, Phoenix and its affiliates
and their directors, trustees, officers, employees, representatives and/or
agents, will be held harmless for any claim, liability, loss or cost.
[ ] Yes [ ] No
--------------------------------------------------------------------------------
ELECTRONIC DELIVERY AUTHORIZATION
--------------------------------------------------------------------------------
By checking "Yes," I am authorizing Phoenix to provide my statements,
prospectuses and other information electronically if available. I understand
that, I must have internet access to use this service and there may be access
fees charged by the internet service provider. [ ] Yes [ ] No
--------------------------------------------------------------------------------
OWNER(S) ACKNOWLEDGEMENTS
--------------------------------------------------------------------------------
The following states require the applicant to acknowledge the information below
that pertains to his or her specific state. Check the appropriate box for your
resident state, sign and date the bottom of this section.
<TABLE>
<CAPTION>
<S> <C> <C> <C> <C> <C>
[ ]ARKANSAS [ ]KENTUCKY [ ]MAINE [ ]NEW MEXICO [ ]OHIO [ ]PENNSYLVANIA
</TABLE>
Any person who knowingly and with intent to defraud any insurance company or
other person and who files an application for insurance or statement of
claim containing any materially false information or conceals for the
purpose of misleading information concerning any false materials thereto
commits a fraudulent insurance act which is a crime and subjects such person
to criminal and civil penalties.
[ ]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.
[ ]COLORADO - It is unlawful to knowingly provide false, incomplete,
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 policyholder or claimant
for the purpose of defrauding or attempting to defraud the policyholder 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 Services.
[ ]DISTRICT OF COLUMBIA - 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.
[ ]FLORIDA [ ]GEORGIA [ ]VERMONT
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.
[ ]LOUISIANA [ ]OREGON
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.
[ ]NEW JERSEY - Any person who includes any false or misleading information on
an application for an annuity contract is subject to criminal and civil
penalties.
[ ]I WOULD LIKE TO RECEIVE A STATEMENT OF ADDITIONAL INFORMATION (SAI).
[ ]I/WE HAVE READ THE DISCLOSURE STATEMENT ABOVE.
I/WE UNDERSTAND THAT ANNUITY PAYMENTS OR SURRENDER VALUES, WHEN BASED UPON THE
INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT ARE VARIABLE AND NOT GUARANTEED AS
TO A FIXED DOLLAR AMOUNT.
I have read the above statements and represent that they are complete and true
to the best of my knowledge and belief. I acknowledge receipt of a variable
annuity and fund prospectuses. By accepting the annuity issued, I agree to any
additions or corrections to this application. I (owner) confirm that any Social
Security/Taxpayer ID Number is correct as it appears on this application.
Annuitant's Signature _____________________________________(if other than owner)
Owner's Signature _________________ Joint Owner's Signature____________________
Signed at _____________________________ ______________________________________
City, State Date
Do you, as Agent, have reason to believe the product applied for will replace
existing annuities or insurance? [ ] Yes [ ] No
Licensed Agent __________________ _________________ _______________ ________
Signature Print Name Agent ID Number % Shares
Licensed Agent __________________ _________________ _______________ ________
Signature Print Name Agent ID Number % Shares
__________________ _________________ _________________________
Broker/Dealer Firm Address Select Option
[ ] Option 1 [ ] Option 2
[ ] Option 3
__________________ _________________ _________________________
Date Telephone Licensed I.D. No. (for
Florida Agents only)
--------------------------------------------------------------------------------
OL3140 3 11-00
