EX-99.5(B) 5 a19-23320_1ex99d5b.htm EX-99.5(B)

Exhibit 99.5(b)

 

CCSUP

 

PACIFIC LIFE INSURANCE COMPANY

Life Insurance Division

P.O. Box 2030 · Omaha, NE 68103-2030

(800) 347-7787 · Fax (866) 964-4860

www.PacificLife.com

 

APPLICATION FOR INDIVIDUAL LIFE INSURANCE —KEYEXEC VUL

PREMIUM ALLOCATION SUPPLEMENT

 

The elections made in this supplement will supersede any elections entered in the Life Application.

 

 Policyowner Name

 Date Corporate Master Application Signed

 

Premium Allocation

Indicate percentage amount to be allocated into each of the investment options below. The total of the percentages from both pages must be 100%.

 

 

Domestic Equity

 

 

Amer Century VP Mid Cap Value

 

 

 

Neuberger Berman AMT Sustainable Equity

 

Amer Funds IS Growth

 

 

 

PSF Comstock (Invesco)

 

Amer Funds IS Growth-Income

 

 

 

PSF Dividend Growth (T. Rowe Price)

 

ClearBridge Var Mid Cap

 

 

 

PSF Equity Index (BlackRock)

 

DFA VA US Large Value

 

 

 

PSF Growth (MFS)

 

DFA VA US Targeted Value

 

 

 

PSF Large-Cap Growth (BlackRock)

 

Fidelity VIP Contrafund

 

 

 

PSF Large-Cap Value (ClearBridge)

 

Fidelity VIP Growth

 

 

 

PSF Main Street Core (Invesco)

 

Fidelity VIP Mid Cap

 

 

 

PSF Mid-Cap Equity (Scout)

 

Fidelity VIP Total Market Index

 

 

 

PSF Mid-Cap Growth (Ivy)

 

Invesco Oppenheimer V.I. Main Street Small Cap

 

 

 

PSF Mid-Cap Value (Boston Partners)

 

Janus Henderson VIT Enterprise

 

 

 

PSF Small-Cap Equity (BlackRock/Franklin)

 

Lord Abbett Ser Fund Developing Growth

 

 

 

PSF Small-Cap Index (BlackRock)

 

M Capital Appreciation (Frontier)

 

 

 

PSF Small-Cap Value (AllianceBernstein)

 

M Large Cap Growth (DSM Capital)

 

 

 

PSF Value Advantage (JPMorgan)

 

M Large Cap Value (AJO)

 

 

 

T. Rowe Price Blue Chip Growth

 

MFS VIT New Discovery Ser

 

 

 

T. Rowe Price Equity Income

 

MFS VIT Value Ser

 

 

 

Vanguard VIF Mid Cap Index

 

 

 

 

 

 

 

Asset Allocation/Balanced

 

 

Amer Funds IS Asset Alloc

 

 

 

PSF DFA Balanced Alloc (PLFA)

 

BlackRock 60/40 Target Alloc ETF V.I.

 

 

 

PSF Pac Dyn — Conserv Growth (PLFA)

 

Fidelity VIP Freedom 2025

 

 

 

PSF Pac Dyn — Growth (PLFA)

 

Fidelity VIP Freedom 2030

 

 

 

PSF Pac Dyn — Mod Growth (PLFA)

 

Fidelity VIP Freedom 2035

 

 

 

PSF Port Opt Aggr-Growth (PLFA)

 

Fidelity VIP Freedom 2045

 

 

 

PSF Port Opt Conserv (PLFA)

 

Fidelity VIP Freedom Income

 

 

 

PSF Port Opt Growth (PLFA)

 

Lazard Retirement Glbl Dyn Multi-Asset

 

 

 

PSF Port Opt Mod (PLFA)

 

MFS VIT Total Return Ser

 

 

 

PSF Port Opt Mod-Conserv (PLFA)

 

PIMCO VIT Glbl Managed Asset Alloc

 

 

 

 

 

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Premium Allocation (Continued)

 

International Equity

 

 

Sector/Specialty

 

Amer Funds IS Intl

 

 

 

MFS VIT Utilities Ser

 

Amer Funds IS New World

 

 

 

PSF Health Sciences (BlackRock)

 

DFA VA Intl Small

 

 

 

PSF Real Estate (Principal REI)

 

DFA VA Intl Value

 

 

 

PSF Technology (MFS)

 

Fidelity VIP Intl Index

 

 

 

VanEck VIP Glbl Hard Assets

 

Invesco Oppenheimer V.I. Glbl

 

 

 

Vanguard VIF Real Estate Index

 

Invesco V.I. Intl Growth

 

 

Fixed Account Options

 

Janus Henderson VIT Overseas

 

 

 

Pacific Life-Fixed Account

 

M Intl Equity (DFA)

 

 

 

Pacific Life-Fixed LT Account

 

PSF Emerging Markets (Invesco)

 

 

Cash Equivalents

 

PSF Intl Large-Cap (MFS)

 

 

 

Fidelity VIP Govt Money Market

 

PSF Intl Small-Cap (QS Investors)

 

 

Other Approved Investment Options

 

Templeton Foreign VIP

 

 

 

 

 

Fixed Income

 

 

 

 

 

 

Amer Funds IS High-Income Bond

 

 

 

 

 

 

DFA VA Short-Term Fixed

 

 

 

 

 

 

Fidelity VIP Bond Index

 

 

 

 

 

 

Lord Abbett Ser Fund Bond Debenture

 

 

 

 

 

 

Lord Abbett Ser Fund Total Return

 

 

 

 

 

 

PIMCO VIT Income Fund

 

 

 

 

 

 

PSF Core Income (PAM)

 

 

 

 

 

 

PSF Diversified Bond (Western Asset)

 

 

 

 

 

 

PSF Emerging Markets Debt (Ashmore)

 

 

 

 

 

 

PSF Floating Rate Income (PAM)

 

 

 

 

 

 

PSF High Yield Bond (PAM)

 

 

 

 

 

 

PSF Inflation Managed (PIMCO)

 

 

 

 

 

 

PSF Managed Bond (PIMCO)

 

 

 

 

 

 

PSF Short Duration Bond (T. Rowe Price)

 

 

 

 

 

 

Templeton Glbl Bond VIP

 

 

 

 

 

 

Western Asset Global High Yield Bond

 

 

 

 

 

 

Must Total 100%

 

 

 

 

 

 

Declarations

I understand and agree to the following:

1.        This Application supplement will be attached to and made part of the Policy.

2.        This Application supplement will supersede any investment options selected in the Corporate Master Application.”

Signatures

 

Fraud Notice: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

 

If you are signing on behalf of an entity, you represent that you are authorized to execute this document and to make the representations herein. If the entity is a Corporation, you further represent that all requirements under applicable law and under the Corporation’s governing documents have been satisfied concerning the execution of this document, including the use of the corporate seal and number of signing officers.

 

Date Signed:

 

 

 

 

 

 

X

 

Print Name: First, Middle, Last             (Title, if applicable)

Policyowner’s Signature

 

 

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