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EXHIBIT 5(b)
"DRAFT" PACIFIC LIFE
[LOGO OF PACIFIC LIFE] VARIABLE ANNUITY
PAC APP is not available for transfers, 1035 exchanges PAC APP
and 401, 403, 457 and Keogh Plans. Please use the
standard application.
PRODUCT:
[_] Pacific Odyssey [_] Pacific One [_] Pacific Portfolios [_] Pacific Value
________________________________________________________________________________
[1] ANNUITANT Name Birth Date (mo/day/yr) Phone Number
(First, Middle Initial, Last) ( )
________________________________________________________________________________
Street Address Sex
(Number, Street Name and Apartment or Unit Number) [_]M [_]F
_______________________________________________________________________________
City, State & ZIP Code Social Security/Tax ID Number
_______________________________________________________________________________
OPTIONAL
[2] ADDITIONAL ANNUITANT
Check one [_] Joint [_] Contingent
Name (First, Middle Initial, Last) Birth Date Annuitant's Spouse?
(mo/day/yr) [_] Yes [_] No
_______________________________________________________________________________
Street Address Sex
(Number, Street Name and Apartment or Unit Number) [_] M [_] F
_______________________________________________________________________________
City, State & ZIP Code Social Security/Tax ID Number
_______________________________________________________________________________
[3] OWNER Name (First, Middle Initial, Last) Birth Date Phone Number
complete if different than annuitant. (mo/day/yr) ( )
_______________________________________________________________________________
Street Address Sex
(Number, Street Name and Apartment or Unit Number) [_] M [_] F
_______________________________________________________________________________
City, State & ZIP Code Social Security/Tax ID Number
_______________________________________________________________________________
OPTIONAL
[4] OWNER Name Birth Date Annuitant's Spouse?
(First, Middle Initial, Last) (mo/day/yr) [_] Yes [_] No
_______________________________________________________________________________
Street Address Sex
(Number, Street Name and Apartment or Unit Number) [_] M [_] F
_______________________________________________________________________________
City, State & ZIP Code Social Security/Tax ID Number
_______________________________________________________________________________
[5] BENEFICIARY Name Relationship Select One
(First, Middle Initial, Last) [_] Primary [_] Contingent
_______________________________________________________________________________
Name Relationship Select One
(First, Middle Initial, Last) [_] Primary [_] Contingent
_______________________________________________________________________________
[6] CONTRACT TYPE Select one. For SIMPLE IRA, IRA Contribution
write employer name, address and phone
number in Special Remarks section below. $ ______ for tax year _____
$ ______ for tax year _____
[_] Non-Qualified [_] Conduit IRA
[_] Roth IRA [_] IRA
[_] SEP-IRA [_] SIMPLE IRA
_______________________________________________________________________________
[7] REPLACEMENT OF ANNUITY Will the purchase of this annuity replace or
exchange any existing life insurance or annuity? [_] Yes [_] No
_______________________________________________________________________________
[8] TRADE INFORMATION DEATH BENEFITS Subject to state
Premium Submitted State of Sale approval. Call (800) 722-2333 for
state availability.
__________________________________________
Client Acct.# Contract # (for add'l. PACIFIC PORTFOLIOS: [_] Standard
pmts. only) [_] Enhanced
PACIFIC VALUE: [_] Standard
[_] Stepped-Up
[_] Premier
_______________________________________________________________________________
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<S> <C> <C> <C> <C> <C>
[9] ALLOCATION OPTIONS Growth LT _____ [xxxxxxxxxxx] _____ Additional Options
Allocate payment of Fixed _____ Equity Income _____ [xxxxxxxxxxx] _____ FOR PORTFOLIOS ONLY
the amount shown Money Market _____ Multi-Strategy _____ [xxxxxxxxxxx] _____
below. Allocations High Yield Bond _____ Equity _____ [xxxxxxxxxxx] _____ 3-year GIO _____
must total 100% or Managed Bond _____ Equity Index _____ [xxxxxxxxxxx] _____ 6-year GIO _____
equal total premium Govt. Securities _____ International _____ [xxxxxxxxxxx] _____ 10-year GIO _____
invested. Aggressive Equity _____ Emerging Markets _____ DCA Plus _____
$
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[10] REBALANCING Optional. Choose one frequency.
[_] Yes [_] No [_] Quarterly [_] Semi-Annually [_] Annually
_______________________________________________________________________________
[11] DOLLAR COST AVERAGING Choose one of the three following methods
1 [_] Deplete the source account in _____ transfers;
2 [_] Transfer $_____ or _____% annually from each source account; OR
3 [_] Earnings Sweep.
START DATE:__________ FREQUENCY: [_] Monthly [_] Quarterly
[_] Semi-Annually [_] Annually TERM: [_] _____ Months [_] _____ Yrs.
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<S> <C> <C> <C> <C> <C>
Money Market _____ Aggressive Equity _____ Equity _____ [xxxxxxxxxxx] _____ [xxxxxxxxxxx] _____
High Yield Bond _____ Growth LT _____ Equity Index _____ [xxxxxxxxxxx] _____ [xxxxxxxxxxx] _____
Managed Bond _____ Equity Income _____ International _____ [xxxxxxxxxxx] _____ [xxxxxxxxxxx] _____
Govt. Securities _____ Multi-Strategy _____ Emerging Markets _____ [xxxxxxxxxxx] _____
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_______________________________________________________________________________
[12] DEALER INFORMATION SS# Broker/Dealer Name
Registered Representative Name
_______________________________________________________________________________
[13] COMMISSION OPTIONS Check one option for product sold.
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PSVA (SELECT) PACIFIC ONE PACIFIC PORTFOLIOS PACIFIC VALUE
Upfront, Ann. Trail Upfront, Ann. Trail Upfront, Ann. Trail Upfront, Ann. Trail
<S> <C> <C> <C> <C>
A [_] 6%, NA [_] 1%, .25% Q5+ [_] 6.5%, NA [_] TBD
B [_] 5%, .25% Q5-20 [_] .25%, .25% Q2+ [_] 5%, .25% Q5-24 [_] TBD
1% Q21+ 1% Q25+ [_] TBD
C [_] NA [_] NA [_] 3.5%, .5% Q5-24 [_] TBD
1% Q25+
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_______________________________________________________________________________
[14] SPECIAL REMARKS
_______________________________________________________________________________
PACP 8/98 [BAR CODE]
