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Exhibit 5.(a)(2)
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MAILING INSTRUCTIONS: Send this completed application as follows:
IF YOU NEED ASSISTANCE IN COMPLETING THIS FORM, PLEASE CALL (800) 722-2333.
APPLICATIONS WITH PAYMENT (AND/OR ADDITIONAL PAYMENTS):
REGULAR MAIL DELIVERY: Pacific Life Insurance Company,
P.O. Box 100060, Pasadena, CA 91189-0060
EXPRESS MAIL DELIVERY: Pacific Life Insurance Company,
C/O FCNPC, 1111 S. Arroyo Parkway, Ste. 150, Pasadena, CA 91105
APPLICATIONS WITHOUT PAYMENT:
REGULAR MAIL DELIVERY: Pacific Life Insurance Company,
P.O. Box 7187, Pasadena, CA 91109-7187
EXPRESS MAIL DELIVERY: Pacific Life Insurance Company,
1111 S. Arroyo Parkway, Ste. 205, Pasadena, CA 91105
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1. OWNER IF TRUST IS OWNER, ALSO COMPLETE TRUST AGREEMENT CERTIFICATION FORM. CHECK PRODUCT GUIDELINES FOR MAXIMUM ISSUE AGE.
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Name (FIRST, MIDDLE INITIAL, LAST) Birth Date (MO/DAY/YR) Sex
__/__/____ |_|M |_|F
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Street Address City, State, ZIP Code SSN/TIN
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ADDITIONAL OWNER NOT APPLICABLE FOR QUALIFIED CONTRACTS. CHECK ONE: |_| JOINT |_| CONTINGENT
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Name (FIRST, MIDDLE INITIAL, LAST) Birth Date (MO/DAY/YR) Sex
__/__/____ |_|M |_|F
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Street Address City, State, ZIP Code SSN/TIN
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2. ANNUITANT IF OWNER(S) AND ANNUITANT(S) ARE THE SAME, IT IS NOT NECESSARY TO COMPLETE THIS SECTION. CHECK PRODUCT GUIDELINES
FOR MAXIMUM ISSUE AGE.
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Name (FIRST, MIDDLE INITIAL, LAST) Birth Date (MO/DAY/YR) Sex
__/__/____ |_|M |_|F
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Street Address City, State, ZIP Code SSN
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ADDITIONAL ANNUITANT COMPLETE THIS SECTION TO NAME ADDITIONAL ANNUITANT. NOT APPLICABLE FOR QUALIFIED CONTRACTS.
CHECK ONE: |_| JOINT |_| CONTINGENT
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Name (FIRST, MIDDLE INITIAL, LAST) Birth Date (MO/DAY/YR) Sex
__/__/____ |_|M |_|F
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Street Address City, State, ZIP Code SSN
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3. BENEFICIARIES IF NO BOXES ARE CHECKED, DEFAULT WILL BE JOINT PRIMARY BENEFICIARIES. UNLESS OTHERWISE INDICATED, PROCEEDS
WILL BE DIVIDED EQUALLY. USE SPECIAL REQUESTS SECTION TO PROVIDE ADDITIONAL BENEFICIARIES OR BENEFICIARY INFORMATION.
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Name (FIRST, MIDDLE INITIAL, LAST) |_| PRIMARY Relationship Percentage
|_| CONTINGENT %
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Name (FIRST, MIDDLE INITIAL, LAST) |_| PRIMARY Relationship Percentage
|_| CONTINGENT %
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4. CONTRACT TYPE SELECT ONE.
|_| Non-Qualified |_| SIMPLE IRA(1) |_| Custodial IRA |_| 457
|_| Conduit IRA |_| SEP-IRA |_| 401(a) Pension(2) |_| Keogh/HR10(2)
|_| IRA |_| Contributory Roth IRA |_| 401(k)(2) |_| TSA/403(b)(3)
|_| Conversion Roth IRA Conversion Date __/__/____
(1)COMPLETE ROTH/SIMPLE FORM. (2)COMPLETE QUALIFIED PLAN CERTIFICATION FORM. (3)COMPLETE TSA CERTIFICATION FORM.
QUALIFIED CONTRACT PAYMENT TYPE
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IF NO YEAR IS INDICATED, CONTRIBUTION DEFAULTS TO CURRENT TAX YEAR.
|_| Transfer.............$____________
|_| Rollover.............$____________
|_| Contribution.........$____________ for tax year ____________
5. INITIAL PURCHASE PAYMENT
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INDICATE THE FORM OF INITIAL PAYMENT. CHECK PAYABLE TO PACIFIC LIFE INSURANCE COMPANY.
|_| 1035 EXCHANGE/EST. TRANSFER $____________ |_| AMT. ENCLOSED $____________
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6. OPTIONAL DEATH BENEFIT
SUBJECT TO STATE AVAILABILITY. ANNUITANT(S) MUST NOT BE OVER 75 AT ISSUE. IF AN OPTION IS NOT SELECTED, THE STANDARD DEATH
BENEFIT IS THE DEFAULT.
|_| Standard Death Benefit |_| Stepped-Up Death Benefit
|_| Premier Death Benefit
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7. REPLACEMENT Will the purchase of this annuity result in the replacement, termination or change in value of any existing
life insurance or annuity in this or any other company? |_| Yes |_| No
IF YES, PROVIDE THE INFORMATION BELOW AND ATTACH ANY REQUIRED STATE REPLACEMENT AND/OR 1035 EXCHANGE/TRANSFER FORMS. USE THE
SPECIAL REQUESTS SECTION FOR ADDITIONAL INSURANCE COMPANIES AND CONTRACT NUMBERS.
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Insurance Company Name Contract Number Contract Type Being Replaced
|_| Life Insurance
|_| Fixed Annuity
|_| Variable Annuity
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8. TELEPHONE/ELECTRONIC AUTHORIZATION
I WILL RECEIVE THIS PRIVILEGE AUTOMATICALLY. By checking "yes," I am authorizing and directing Pacific Life to act on telephone
or electronic instructions from any other 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 armless for
any claim, liability, loss or cost. |_| Yes
9. ELECTRONIC DELIVERY AUTHORIZATION
By checking "yes," I authorize Pacific Life to provide my statements, prospectuses and other information electronically.
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
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Email address:_________________________________________@_________________________________________
25-13000
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10. SPECIAL REQUESTS IF ADDITIONAL SPACE IS NEEDED, ATTACH LETTER SIGNED AND DATED BY OWNER(S).
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11. ALLOCATION OPTIONS USE WHOLE PERCENTAGES ONLY. ALLOCATIONS MUST EQUAL 100%.
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MANAGER: PORTFOLIO: MANAGER: PORTFOLIO:
________% AIM.............................BLUE CHIP ________% Janus.......................FOCUSED 30
________AIM...............................AGGRESSIVE GROWTH ________Lazard........................MID-CAP VALUE
________Alliance Capital..................AGGRESSIVE EQUITY ________Lazard........................INTERNATIONAL VALUE
________Alliance Capital..................EMERGING MARKETS ________MFS...........................CAPITAL OPPORTUNITIES
________Capital Guardian..................DIVERSIFIED RESEARCH ________MFS...........................MID-CAP GROWTH
________Capital Guardian..................SMALL-CAP EQUITY ________MFS...........................GLOBAL GROWTH
________Capital Guardian..................INTERNATIONAL LARGE-CAP ________Mercury Advisors.............EQUITY INDEX
________Goldman Sachs.....................EQUITY ________Mercury Advisors.............SMALL-CAP INDEX
________Goldman Sachs.....................I-NET TOLLKEEPER ________Morgan Stanley...............REIT
________INVESCO...........................FINANCIAL SERVICES ________PIMCO.........................GOVERNMENT SECURITIES
________INVESCO...........................HEALTH SCIENCES ________PIMCO.........................MANAGED BOND
________INVESCO...........................TECHNOLOGY ________Pacific Life..................MONEY MARKET
________INVESCO...........................TELECOMMUNICATIONS ________Pacific Life.................HIGH YIELD BOND
________J.P. Morgan.......................MULTI-STRATEGY ________Salomon.......................LARGE-CAP VALUE
________J.P. Morgan.......................EQUITY INCOME ________Pacific Life.................FIXED
________Janus.............................STRATEGIC VALUE
________Janus.............................GROWTH LT ________TOTAL MUST EQUAL 100%
12. STATEMENT OF APPLICANT I received prospectuses for this variable annuity contract. After reviewing my financial background
with my agent, I believe this contract will meet my insurable needs and financial objectives. If applicable, I considered the
appropriateness of full or partial replacement of any existing life insurance or annuity. I understand that as a result of
the investment experience of the variable investment options, my contract value may increase or decrease and is not guaranteed.
I discussed the fees and charges for this contract with my agent, including withdrawal charges.
If there are joint applicants, the issued contract will be owned by the joint applicants as Joint Tenants With Right of
Survivorship and not as Tenants in Common.
My signature certifies that the taxpayer identification number is correct. The following sentence applies only if you are not
subject to withholding. I am not subject to backup withholding either because: 1) I am exempt; 2) I have not been notified
that I am subject to backup withholding resulting from failure to report all interest or dividends; 3) I have been notified
that I am no longer 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.
THESE STATES REQUIRE INSURANCE COMPANIES TO PROVIDE A FRAUD WARNING STATEMENT. PLEASE REFER TO THE FRAUD WARNING STATEMENT FOR
YOUR STATE AS INDICATED BELOW. PLEASE CHECK FOR STATE PRODUCT AVAILABILITY.
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.
NEW JERSEY Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
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Signed at: City State Solicited at: State
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VIRGINIA It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the company.
Penalties include imprisonment, fines and denial of insurance benefits.
WASHINGTON Any person who knowingly presents a false or fraudulent claim for
payment of a loss or knowingly makes a false statement in an application for
insurance may be guilty of a criminal offense under law.
ALL OTHER STATES: 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 may be a crime and may subject such
person to criminal and civil penalties.
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Owner's Signature Date
Sign here: __/__/____
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Joint Owner's Signature IF APPLICABLE Date
Sign here: __/__/____
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13. AGENT'S STATEMENT Do you have reason to believe that any existing life insurance or annuity has been (or will be)
surrendered, withdrawn from, loaned against, changed or otherwise reduced in value, or replaced in connection with this
transaction assuming the contract applied for will be issued? |_| YES |_| NO IF YES, EXPLAIN IN REPLACEMENT SECTION.
I have explained to the applicant how the annuity will meet their insurable needs and financial objectives. I have discussed
the appropriateness of replacement, and followed Pacific Life's written replacement guidelines.
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Soliciting Agent's Signature Print Agent's Full Name Agent's ID Number
Sign here:
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Agent's Phone Number Agent's E-Mail Address Option
|_|A
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Broker/Dealer's Name Brokerage Account Number OPTIONAL.
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