EX-5.D 5 dex5d.txt EXHIBIT-5.D EXHIBIT (5)(d) FORM OF APPLICATION FOR INDIVIDUAL CONTRACT -------------------------------------------------------------------------------------------------------------- Mail the application and a check to: Product Name: TRIPLE ADVANTAGE Transamerica Occidental Transamerica Occidental Life Insurance Company ----------------- Attn: Variable Annuity Dept. Variable Annuity Life Insurance Company 4333 Edgewood Road N.E. Application [LOGO] Cedar Rapids, IA 52499-0001 ---------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------- 1. OWNER INFORMATION (If no Annuitant is specified in #2, --------------------- the Owner will be the Annuitant.) In the event the owner and/or beneficiary is a trust, MUST COMPLETE and SUBMIT the "Trustee Certification of Trust" form. First Name:_____________________________________________________________________ Last Name:______________________________________________________________________ Address:________________________________________________________________________ City, State:____________________________________________________________________ Zip:___________________ Telephone:______________________________________________ Date of Birth:______________________________________________ Sex: [_] Female SS#/TIN:____________________________________________________ [_] Male -------------------------------------------------------------------------------- 1b. JOINT OWNER(S) ------------------ First Name:_____________________________________________________________________ Last Name:______________________________________________________________________ Address:________________________________________________________________________ City, State:____________________________________________________________________ Zip:___________________ Telephone:______________________________________________ Date of Birth:______________________________________________ Sex: [_] Female SS#/TIN:____________________________________________________ [_] Male -------------------------------------------------------------------------------- 2. ANNUITANT Complete only if different from Owner. ------------- First Name:_____________________________________________________________________ Last Name:______________________________________________________________________ Address:________________________________________________________________________ City, State:____________________________________________________________________ Zip: __________________ Telephone:______________________________________________ Date of Birth:______________________________________________ SS#/TIN:____________________________________________________ -------------------------------------------------------------------------------- 3. BENEFICIARY(IES) DESIGNATION -------------------------------- Primary Contingent Name Relationship [_] [_] _______________________________________________________________% [_] [_] _______________________________________________________________% [_] [_] _______________________________________________________________% -------------------------------------------------------------------------------- 4. TYPE OF ANNUITY ------------------- [_] Non-qualified Qualified Types: [_] IRA [_] Roth IRA [_] SEP/IRA [_] 403(b) [_] Keogh [_] Roth Conversion [_] Other________________________________ IRA / SEP / ROTH IRA $_______________ Contribution for tax year__________________________ $_______________ Trustee to Trustee Transfer $_______________ Rollover from [_] IRA [_] 403(b) [_] Pension [_] Other ROTH IRA Rollover _______________________ Date first established or date of conversion $______________________ Portion previously taxed -------------------------------------------------------------------------------- 5. GUARANTEED MINIMUM DEATH BENEFITS ------------------------------------ Your selection cannot be changed after the policy has been issued. If no option is specified, the Return of Premium Death Benefit will apply. [_] Double Enhanced Death Benefit, available for issue through age 80. Daily M&E Risk Fee and Administrative Charge is 1.45% annually. [_] Return of Premium Death Benefit, available for issue through age 90. Daily M&E Risk Fee and Administrative Charge is 1.30% annually. -------------------------------------------------------------------------------- 6. GUARANTEED MINIMUM INCOME BENEFIT RIDER ------------------------------------------ Must complete this section. If no selection is made, the GMIB option will not apply. (Available at an additional cost. Please see prospectus for information on the terms of the Rider.) [_] I/We elect Guaranteed Minimum Income Benefit Rider -------------------------------------------------------------------------------- 7. TAX RELIEF RIDER ------------------- (Available at an additional cost. Please see prospectus for information on the terms of the Rider.) [_] I/We wish to elect the Tax Relief Rider -------------------------------------------------------------------------------- 8. TELEPHONE TRANSFER AUTHORIZATION ----------------------------------- Please complete this section to authorize you and/or your Registered Representative to make transfer requests via our recorded telephone line. (check one selection only): [_] Owner(s) only, or [_] Owner(s) and Owner's Registered Representative -------------------------------------------------------------------------------- 9. REBALANCING -------------- [_] Quarterly [_] Semi-Annually [_] Annually I elect to rebalance the variable subaccounts according to my Allocation of Purchase Payments using the frequency indicated above (Not available with DCA). If you would like to rebalance to a mix other than the indicated Allocation of Purchase Payments, please complete the Optional Programs Form. DVA-APP 1201 813-A-0502 Triple Advantage 5/02 8132132 5/02 -------------------------------------------------------------------------------- 10. ALLOCATION OF PURCHASE PAYMENTS ----------------------------------- The invested amount will be allocated as indicated below. If Dollar Cost Averaging, Section 11 must be completed in order to begin the Dollar Cost Averaging Program. Initial Purchase Payments $___________ Make check payable to Transamerica Occidental Life Insurance Company. DOLLAR COST AVERAGING ACCOUNT ________ .0% (Must also complete Section 11 Dollar Cost Averaging Program) SUBACCOUNTS: Dreyfus Appreciation Portfolio - Service Class _______ .0% Dreyfus Balanced Portfolio - Service Class _______ .0% Dreyfus Core Bond Portfolio - Service Class _______ .0% Dreyfus Core Value Portfolio - Service Class _______ .0% Dreyfus Disciplined Stock Portfolio - Service Class _______ .0% Dreyfus Emerging Leaders Portfolio - Service Class _______ .0% Dreyfus Emerging Markets Portfolio - Service Class _______ .0% Dreyfus European Equity Portfolio - Service Class _______ .0% Dreyfus Founders Discovery Portfolio - Service Class _______ .0% Dreyfus Founders Growth Portfolio- Service Class _______ .0% Dreyfus Founders International Equity Portfolio - Service Class _______ .0% Dreyfus Founders Passport Portfolio - Service Class _______ .0% Dreyfus Growth and Income Portfolio - Service Class _______ .0% Dreyfus International Equity Portfolio - Service Class _______ .0% Dreyfus International Value Portfolio - Service Class _______ .0% Dreyfus Japan Portfolio - Service Class _______ .0% Dreyfus Limited Term High Income Portfolio - Service Class _______ .0% Dreyfus MidCap Stock Portfolio - Service Class _______ .0% Dreyfus Money Market Portfolio _______ .0% Dreyfus Quality Bond Portfolio - Service Class _______ .0% Dreyfus Small Cap Portfolio - Service Class _______ .0% Dreyfus Small Company Stock Portfolio - Service Class _______ .0% Dreyfus Socially Responsible Growth Fund, Inc. - Service Class _______ .0% Dreyfus Special Value Portfolio - Service Class _______ .0% Dreyfus Stock Index Fund - Service Class _______ .0% Dreyfus Technology Growth Portfolio - Service Class _______ .0% Transamerica Equity _______ .0% _________________________________________________ _______ .0% _________________________________________________ _______ .0% _________________________________________________ _______ .0% _________________________________________________ _______ .0% FIXED ACCOUNTS: 1 Year Fixed _______ .0% 3 Year Fixed _______ .0% 5 Year Fixed _______ .0% 7 Year Fixed _______ .0% TOTAL VARIABLE AND FIXED 100% -------------------------------------------------------------------------------- 11. DOLLAR COST AVERAGING PROGRAM --------------------------------- If DCA is selected as an initial purchase payments allocation option under Section 10, please complete the following information to provide allocations in order to start the Dollar Cost Averaging Program. SPECIAL DCA FIXED ACCOUNTS: [_] Special 6-month DCA Fixed Account (when available) [_] Special 12-month DCA Fixed Account (when available) DCA FIXED ACCOUNTS: Specify fixed account and frequency of transfer. Minimum transfer $250; monthly (6-60); quarterly (4-20). [_] Money Market __Monthly __Quarterly ___#Transfers [_] 1 Year Fixed Account __Monthly __Quarterly ___#Transfers [_] Quality Bond __Monthly __Quarterly ___#Transfers [_] Limited Term High Income __Monthly __Quarterly ___#Transfers TRANSFER TO SUBACCOUNTS: Dreyfus Appreciation Portfolio - Service Class ________ .0% Dreyfus Balanced Portfolio - Service Class ________ .0% Dreyfus Core Bond Portfolio - Service Class ________ .0% Dreyfus Core Value Portfolio - Service Class ________ .0% Dreyfus Disciplined Stock Portfolio - Service Class ________ .0% Dreyfus Emerging Leaders Portfolio - Service Class ________ .0% Dreyfus Emerging Markets Portfolio - Service Class ________ .0% Dreyfus European Equity Portfolio - Service Class ________ .0% Dreyfus Founders Discovery Portfolio - Service Class ________ .0% Dreyfus Founders Growth Portfolio- Service Class ________ .0% Dreyfus Founders International Equity Portfolio - Service Class ________ .0% Dreyfus Founders Passport Portfolio - Service Class ________ .0% Dreyfus Growth and Income Portfolio - Service Class ________ .0% Dreyfus International Equity Portfolio - Service Class ________ .0% Dreyfus International Value Portfolio - Service Class ________ .0% Dreyfus Japan Portfolio - Service Class ________ .0% Dreyfus Limited Term High Income Portfolio - Service Class ________ .0% Dreyfus MidCap Stock Portfolio - Service Class ________ .0% Dreyfus Money Market Portfolio ________ .0% Dreyfus Quality Bond Portfolio - Service Class ________ .0% Dreyfus Small Cap Portfolio - Service Class ________ .0% Dreyfus Small Company Stock Portfolio - Service Class ________ .0% Dreyfus Socially Responsible Growth Fund, Inc. - Service Class ________ .0% Dreyfus Special Value Portfolio - Service Class ________ .0% Dreyfus Stock Index Fund - Service Class ________ .0% Dreyfus Technology Growth Portfolio - Service Class ________ .0% Transamerica Equity ________ .0% __________________________________________________ ________ .0% __________________________________________________ ________ .0% __________________________________________________ ________ .0% TOTAL MUST = 100% DVA-APP 1201 (2) -------------------------------------------------------------------------------- 12. SIGNATURE(S) OF AUTHORIZATION ACCEPTANCE -------------------------------------------- . Unless I have notified the Company of a community or marital property interest in this contract, the Company will rely on good faith belief that no such interest exists and will assume no responsibility for inquiry. . To the best of my knowledge and belief, my answers to the questions on this application are correct and true, and I agree that this application becomes a part of the annuity contract when issued to me. . I am in receipt of a current prospectus for this variable annuity. . This application is subject to acceptance by Transamerica Occidental Life Insurance Company. If this application is rejected for any reason, Transamerica Occidental Life Insurance Company will be liable only for return of purchase payments paid. [_] Check here if you want a copy of "Statement of Additional Information" sent to you. Will this annuity replace or change any existing annuity or life insurance? [_] No [_] Yes (If yes, complete the following) Company: _______________________________________________________________________ Policy No.: ____________________________________________________________________ I HAVE REVIEWED MY EXISTING ANNUITY COVERAGE AND FIND THIS COVERAGE SUITABLE FOR MY NEEDS. -------------------------------------------------------------------------------- For applicants in all state except Connecticut, New Jersey, Pennsylvania, and Washington. When funds are allocated in Fixed Options Guarantee periods, account values under contract may increase or decrease in accordance with Excess Interest Adjustment prior to the end of Guaranteed Period. -------------------------------------------------------------------------------- Account values when allocated to any of the Variable Options are not guaranteed as to fixed dollar amount. Signed at: _____________________________________________________________________ City State Date Owner(s) Signature: ____________________________________________________________ Joint Owner(s) Signature: ______________________________________________________ Annuitant Signature: (if not Owner) ____________________________________________ -------------------------------------------------------------------------------- 13. AGENT INFORMATION --------------------- Do you have any reason to believe the annuity applied for will replace or change any existing annuity or life insurance? [_] No [_] Yes I HAVE REVIEWED THE APPLICANT'S EXISTING ANNUITY COVERAGE AND FIND THIS COVERAGE IS SUITABLE FOR HIS/HER NEEDS. Registered Rep/Licensed Agent Name: Please print First Name: _______________________________________________________ Please print Last Name: ________________________________________________________ Signature:______________________________________________________________________ Rep Phone #: ___________________________________________________________________ SS # / TIN: ____________________________________________________________________ Rep. License #: ________________________________________________________________ Firm Name: _____________________________________________________________________ Firm Address: __________________________________________________________________ For Registered Representative Use Only - Contact your home office for program information. [_] Option A [_] Option B [_] Option C [_] Option D (Once selected program cannot be changed) -------------------------------------------------------------------------------- For applicants in the following states LA, MT or NH: Do you have any existing policies or contracts? [_] No [_] Yes (If yes, you must complete and submit with the application the "Important Notice Replacement of Life Insurance or Annuities".) Did the agent/registered representative present and leave the applicant insurer-approved sales material? [_] No [_] Yes -------------------------------------------------------------------------------- DVA-APP 1201 (3) For applicants in Florida -------------------------------------------------------------------------------- Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. For applicants in Louisiana -------------------------------------------------------------------------------- Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. For applicants in 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. For applicants in Pennsylvania -------------------------------------------------------------------------------- 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.