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"DRAFT"
EXHIBIT 99.5(c)
PACIFIC LIFE APPLICATION/CONFIRMATION FORM [LOGO OF PACIFIC LIFE]
Pacific Life Insurance Company Pacific Odyssey Variable Annuity
PO Box 7187, Pasadena, CA 91109-7187
1111 South Arroyo Parkway, Suite 205
Pasadena, CA 91109-7187
[VA99999999] Initial Premium: [$10,000] Issue Date: [01-01-01]
State of Sale: [STATE]
Please sign and date the form on the reverse side and return it promptly to
Pacific Life in the enclosed postage-paid envelope. This form confirms the
application and receipt of your Contract, Your funds are invested according to
the terms of the contract and prospectus. Carefully review the information on
this form and inform us of any discrepancies immediately, Financial transactions
on this policy cannot be processed prior to the receipt of this signed form.
Please take a moment now to avoid delays in the future.
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ANNUITANT(S): ALLOCATION OPTIONS:
[John Doe]
[123 Any Street] 100% Fixed
[Anytown, State, 12345] 0% Money Market
[###-##-####] [01-01-1948] [MALE] 0% High Yield Bond
----------------------------------------- 0% Managed Bond
Joint/Contingent (J Joint; C Contingent) 0% Government Securities
0% Aggressive Equity
----------------------------------------- 0% Growth LT
OWNER(S): 0% Equity Income
[Jane Doe] 0% Multi-Strategy
[123 Any Street] 0% Equity
[Anytown, State, 12345] 0% Equity Index
[123-45-6789] [01-01-1948] [FEMALE] 0% International Value
----------------------------------------- 0% Emerging Markets
Joint/Contingent (J Joint; C Contingent) 0% [xxxxxxxxxx]
-----------------------------------------
BENEFICIARY/BENEFICIARIES:
(P=Primary; C=Contingent) TYPE OF PLAN: [NON-QUALIFIED]
REBALANCING: [N] [NONE]
[NAME] [P] DEALER INFORMATION:
[NAME]
DEATH BENEFIT OPTION: [OPTION]
REPLACEMENT: [VARIABLE]
DOLLAR COST AVERAGING: [VARIABLE1]
PORTFOLIO OPTIMIZATION: [VARIABLE1]
PRE-AUTHORIZED WITHDRAWAL: [VARIABLE1]
Please See Reverse Side
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TELEPHONE AUTHORIZATION
Owner's initials Joint Owner's initials
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By initialing, Pacific Life is authorized and directed to act on telephone
instructions from any person(s) who can furnish proper identification. Pacific
Life will use reasonable procedures to confirm that these instructions are
authorized and genuine. As long as these procedures are followed, Pacific Life
and its affiliates and their directors, trustees, officers, employees,
representatives and/or agents, will be held harmless for any claim, liability,
loss or cost.
STATEMENT OF APPLICANT
My agent and I discussed my financial background and as a result I believe this
Contract will meet my insurable needs and financial objectives. I have
considered the appropriateness of full or partial replacement of any existing
life insurance or annuity, if applicable. I understand that Contract Values may
increase or decrease depending on the investment experience of the Variable
Accounts. Contract Values under the Variable Accounts are variable and are not
guaranteed. I UNDERSTAND THAT ALL PAYMENTS AND VALUES PROVIDED BY THE CONTRACT
MAY VARY AS TO DOLLAR AMOUNT TO THE EXTENT THAT THEY ARE BASED ON THE INVESTMENT
EXPERIENCE OF THE SELECTED PORTFOLIO(S).
I have received prospectuses. I hereby represent the information provided is
correct and true to the best of my knowledge and belief, and agree that this
application will be part of the annuity Contract issued by Pacific Life. I
acknowledge that corrections to my Contract may be made from the application. My
acceptance of this Contract constitutes acceptance of these corrections. If
there are joint applicants, the Contract, if issued, will be owned by the joint
applicants as Joint Tenants With The Rights Of Survivorship and not as Tenants
in Common.
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 is a crime and subjects such person to criminal and civil penalties.
This Contract is not covered by an insurance guaranty fund or other solvency
protection arrangement, therefore the policyholder bears the risk that the
company will not fulfill its obligations under the Contract.
My signature certifies, under penalty of perjury, that the taxpayer
identification number provided is correct. I am not subject to backup
withholding because; I am exempt; or I have not been notified that I am subject
to backup with-holding resulting from failure to report all interest or
dividends; or I have been notified that I am no longer subject to backup
withholding. (Strike out the preceding sentence if subject to backup
withholding.) The IRS does not require my consent to any provision of this
document other than the certifications required to avoid backup withholding.
I acknowledge that I received this Contract on
---------------------------.
Date
I certify that this Contract was sold and/or solicited in the state of [ISSSTE].
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Date Owner Signature
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Date Joint Owner's Signature
