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EXHIBIT 5.(a)
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[LOGO] PACIFIC LIFE Pacific Life Insurance Company PACIFIC PORTFOLIOS
P.O. Box 7187 . Pasadena, CA 91109-7187 Variable Annuity Application
www.PacificLife.com . (800) 722-2333
MAILING INSTRUCTIONS: Send this APPLICATIONS WITH PAYMENT APPLICATIONS WITHOUT PAYMENT:
completed application as follows: (and/or additional payments): Regular Mail Delivery:
Regular Mail Delivery: Pacific Life Insurance Company,
If you need assistance in Pacific Life Insurance Company, P.O. Box 7187, Pasadena, CA 91109-7187
completing this form, P.O. Box 100060, Pasadena, CA 91189-0060 Express Mail Delivery:
please call (800) 722-2333. Express Mail Delivery: Pacific Life Insurance Company,
Pacific Life Insurance Company, 1111 S. Arroyo Parkway, Ste. 205,
C/O FCNPC, 1111 S. Arroyo Parkway, Ste. 150, Pasadena, CA 91105
Pasadena, CA 91105
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. Qualified Contract Payment Type
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[_] Non-Qualified [_] SIMPLE IRA/1/ [_] Custodial IRA [_] 457 If no year is indicated, contribution defaults
[_] Conduit IRA [_] SEP-IRA [_] 401 (a) Pension/2/ [_] Keogh/HR10/2/ to current tax year.
[_] IRA [_]Contributory Roth IRA [_] 401(k)/2/ [_] TSA/403(b)/3/ [_] Transfer........ $______
[_] Conversion Roth IRA Conversion Date ____/____/________ [_] Rollover........ $______
[_] Contribution.... $______ for tax year _____
/1/ Complete Roth/SIMPLE form. /2/ Complete Qualified Plan Certification form.
/3/ Complete TSA Certification form.
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5. INITIAL PURCHASE PAYMENT 6. OPTIONAL DEATH BENEFIT 7. OPTIONAL GUARANTEED
Indicate the form of initial payment. Subject to state availability. INCOME ADVANTAGE (GIA)
Check payable to Annuitant(s) must not be over 75 Subject to state
Pacific Life Insurance Company. at issue. If an option is not selected, availability. Annuitant(s)
--------------------------------------------------------------- the standard death benefit is must not be over 80 at
[_] 1035 exchange/est. transfer $_____ [_] Amt. enclosed $_____ the default. -------------------------- issue. -------
--------------------------------------------------------------- [_] Standard Death Benefit [_] GIA
[_] Enhanced Death Benefit -------
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8. 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? ----------------- If yes, provide the information below and attach any required
[_] Yes [_] No 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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9. 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 harmless for any claim, liability, loss or cost. [_] Yes
10. 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: _____________________________@_______________.__________ 280-1A [BAR CODE]
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25-12410 *280-1A1*
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11. SPECIAL REQUESTS If additional space is needed, attach letter signed and dated by owner(s).
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12. ALLOCATION OPTIONS Use whole percentages only. Allocations must equal 100%.
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Manager: Portfolio: Manager: Portfolio:
_____% AIM.................. Blue Chip _____% Lazard...................... International Value
______ AIM.................. Aggressive Growth ______ MFS......................... Capital Opportunities
______ Alliance Capital..... Aggressive Equity ______ MFS......................... Mid-Cap Growth
______ Alliance Capital..... Emerging Markets ______ MFS......................... Global Growth
______ Capital Guardian..... Diversified Research ______ Mercury Asset Management.... Equity Index
______ Capital Guardian..... Small-Cap Equity ______ Mercury Asset Management.... Small-Cap Index
______ Capital Guardian..... International Large-Cap ______ Morgan Stanley.............. REIT
______ Goldman Sachs........ Equity ______ PIMCO....................... Government Securities
______ Goldman Sachs........ I-Net Tollkeeper ______ PIMCO....................... Managed Bond
______ INVESCO.............. Financial Services ______ Pacific Life................ Money Market
______ INVESCO.............. Health Sciences ______ Pacific Life................ High Yield Bond
______ INVESCO.............. Technology ______ Salomon..................... Large-Cap Value
______ INVESCO.............. Telecommunications ______ Pacific Life................ Fixed
______ J.P. Morgan.......... Multi-Strategy ______ Pacific Life................ DCA Plus Fixed
______ J.P. Morgan.......... Equity Income ______ Pacific Life................ 3-year GIO
______ Janus................ Strategic Value ______ Pacific Life................ 6-year GIO
______ Janus................ Growth LT ______ Pacific Life................ 10-year GIO
______ Janus................ Focused 30
______ Lazard............... Mid-Cap Value ----------------------------
______ TOTAL MUST EQUAL 100%
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13. 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 notifed 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 Virginia It is a crime to knowingly provide false, incomplete
warning statement. Please refer to the fraud warning statement or misleading information to an insurance company for the
for your state as indicated below. Please check for state purpose of defrauding the company. Penalties include
product availability. imprisonment, fines and denial of insurance benefits.
Colorado It is unlawful to knowingly provide false, incomplete, Washington Any person who knowingly presents a false or
misleading facts or information to an insurance company for the fraudulent claim for payment of a loss or knowingly makes
purpose of defrauding or attempting to defraud the company. a false statement in an application for insurance may be
Penalties may include imprisonment, fines, denial of insurance guilty of a criminal offense under law.
and civil damages. Any insurance company or agent of an
insurance company who knowingly provides false, incomplete or All Other States: Any person who knowingly and with intent
misleading facts or information to a policyholder or claimant to defraud any insurance company or other person files an
for the purpose of defrauding or attempting to defraud the application for insurance or statement of claim containing any
policyholder or claimant with regard to a settlement or award materially false information or conceals for the purpose of
payable from insurance proceeds shall be reported to the misleading, information concerning any fact material thereto
Colorado Division of Insurance within the Department of commits a fraudulent insurance act, which may be a crime and
Regulatory Services. may subject such person to criminal and civil penalties.
New Jersey Any person who includes any false or misleading ------------------------------------------- -----------------
information on an application for an insurance policy is Owner's Signature Date
subject to criminal and civil penalties.
------------------------------ -------- ------------------- [SIGN HERE]________________________________ ____/____/_______
Signed at: City State Solicited at: State ------------------------------------------- -----------------
___ ____ ____ ____ ------------------------------------------- -----------------
------------------------------ -------- ------------------- Joint Owner's Signature if applicable Date
[SIGN HERE]_____________________________ ____/____/_______
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14. 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? ----------------- If yes, explain in Replacement Section.
[_] Yes [_] No
-----------------
[MUST CHECK ONE]
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 [_] B [_]C
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Broker/Dealer's Name Brokerage Account Number Optional. 280-1A [BAR CODE]
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25-12410 *280-1A2*
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