EX-5.E 5 dex5e.txt EXHIBIT 5.E EXHIBIT (5)(e) FORM OF APPLICATION [GRAPHIC] Triple Advantage Variable [GRAPHIC](R) Annuity Application Mail the application and a check to: Transamerica Occidental Life Insurance Company Attn: Variable Annuity Dept. Service Office: P.O. Box 3183, Cedar Rapids, IA 52406-3183 Overnight Mailing Address: 4333 Edgewood Rd. NE, Cedar Rapids, IA 52499 ================================================================================================================================== 1. TYPE OF ANNUITY (SOURCE OF FUNDS) 4. BENEFICIARY(IES) DESIGNATION Initial purchase payment $ _________________________________ Name Relationship [_] Primary [_] Non qualified ___________________ ____________ _____% [_] Contingent [_] New Money [_] 1035 Exchange [_] Qualified Name Relationship [_] Primary [_] New Money [_] Rollover [_] Transfer ___________________ ____________ _____% [_] Contingent Qualified Type: [_] IRA [_] Roth IRA [_] SEP/IRA [_] 403(b) Name Relationship [_] Primary [_] Keogh [_] Roth Conversion [_] Other ____________ ___________________ ____________ _____% [_] Contingent IRA/SEP/ROTH IRA $ ____________ Contribution for tax year ______________ Name Relationship [_] Primary $ ____________ Trustee to Trustee Transfer ___________________ ____________ _____% [_] Contingent $ ____________ Rollover from [_] IRA [_] 403(b) [_] Pension [_] Other ____________ Name Relationship [_] Primary ROTH IRA Rollover ___________________ ____________ _____% [_] Contingent ____________ Date first established or date of conversion $ ____________ Portion previously taxed 2(a). PRIMARY OWNER INFORMATION 5. GUARANTEED DEATH BENEFITS If no Annuitant is specified in #3, the Owner will be the If no option is specified, the Return of Premium Death Annuitant. If a Trust is named as Owner or Beneficiary, Benefit will apply. Your selection cannot be changed after additional paperwork will be required. the policy has been issued. First Name: __________________________________________________ [_] Annual Step-Up Death Benefit Last Name: ___________________________________________________ [_] Return of Premium Death Benefit Address: _____________________________________________________ [_] Double Enhanced Death Benefit City, State: _________________________________________________ Zip: ____________-____________ Telephone: ____________________ Email Address (optional): ____________________________________ Date of Birth: ______________________ Sex: [_] Female [_] Male SSN/TIN: ____________________ Citizenship: [_] U.S. [_] Other 2(b). JOINT OWNER INFORMATION (Optional) 6. OTHER AVAILABLE RIDERS First Name: __________________________________________________ If no selection is made, the benefit will not apply. Last Name: ___________________________________________________ Additional Death Benefit: Address: _____________________________________________________ [_] Yes City, State: _________________________________________________ [_] No Zip: ____________-____________ Telephone: ____________________ Additional Death Benefit II: Date of Birth: ______________________ Sex: [_] Female [_] Male [_] Yes SSN/TIN: ____________________ Citizenship: [_] U.S. [_] Other [_] No 3. ANNUITANT Complete only if different from Primary Owner. First Name: __________________________________________________ Last Name: ___________________________________________________ 7. TELEPHONE TRANSFER AUTHORIZATION Address: _____________________________________________________ Please complete this section to authorize you and/or your Registered Representative to make transfer requests via City, State: _________________________________________________ our recorded telephone line or internet. (check one selection only): Zip: ____________-____________ Telephone: ____________________ [_] Owner(s) only, or [_] Owner(s) and Owner's Registered Email Address (optional): ____________________________________ Representative Date of Birth: ______________________ Sex: [_] Female [_] Male SSN: ________________________ Citizenship: [_] U.S. [_] Other
VA-APP 05/03 8. PORTFOLIO INVESTMENT STRATEGY [_] Lump Sum [_] Combined: Lump Sum and DCA Program (must total 100%) I elect to allocate 100% of my contributions according to I elect to allocate as follows: percentage listed in Section 10 "Lump Sum Allocation ___________% as a lump-sum contributions according to Section". percentages listed in Section 10 "Lump Sum Allocation [_] Dollar Cost Averaging (DCA) Program Section". I elect to allocate 100% of my contributions according to ___________% in the DCA Account and transferred according percentage listed in Section 11 DCA "Transfer Allocation to percentages listed in Section 11 DCA "Transfer Section". Allocation Section". 9. DCA TRANSFER STRATEGY DCA Strategy (There is a $250 minimum transfer amount for the [_] 4. Money Market Account: DCA program.) [_] 12 Mo. [_] 18 Mo. [_] 24 Mo. [_] Other______________________________ Transfer from: (Select 1 of the following) (Specify period and frequency) [_] 5. Quality Bond [_] 1. Special 6 Month DCA Fixed Account [_] 12 Mo. [_] 18 Mo. [_] 24 Mo. [_] Other______________________________ [_] 2. Special 12 Month DCA Fixed Account (Specify period and frequency) [_] 6. Limited Term High Yield [_] 3. DCA Fixed Account*: [_] 12 Mo. [_] 18 Mo. [_] 24 Mo. [_]12 Mo. [_]18 Mo. [_]24 Mo. [_] Other______________________________ [_]Other______________________________ (Specify period and frequency) (Specify period and frequency) Complete Section 11 for DCA transfer allocation. *Washington and Massachusetts residents, DCA cannot exceed twelve months or four quarters. 10. LUMP SUM ALLOCATION 11. DCA TRANSFER ALLOCATION Fixed Accounts: Transfer To: __________.0% 1 Year Fixed Guarantee Period Option __________.0% Dreyfus Appreciation Portfolio - Service Class __________.0% 3 Year Fixed Guarantee Period Option __________.0% Dreyfus Balanced Portfolio - Service Class __________.0% 5 Year Fixed Guarantee Period Option __________.0% Dreyfus Core Bond Portfolio - Service Class __________.0% 7 Year Fixed Guarantee Period Option __________.0% Dreyfus Core Value Portfolio - Subaccounts: Service Class __________.0% Dreyfus Appreciation Portfolio - __________.0% Dreyfus Developing Leaders Portfolio - Service Class Service Class __________.0% Dreyfus Balanced Portfolio - __________.0% Dreyfus Disciplined Stock Portfolio - Service Class Service Class __________.0% Dreyfus Core Bond Portfolio - __________.0% Dreyfus Emerging Leaders Portfolio - Service Class Service Class __________.0% Dreyfus Core Value Portfolio - __________.0% Dreyfus Emerging Markets Portfolio - Service Class Service Class __________.0% Dreyfus Developing Leaders Portfolio - __________.0% Dreyfus Founders Discovery Portfolio - Service Class Service Class __________.0% Dreyfus Disciplined Stock Portfolio - __________.0% Dreyfus Founders Growth Portfolio - Service Class Service Class __________.0% Dreyfus Emerging Leaders Portfolio - __________.0% Dreyfus Founders International Equity Service Class Portfolio - Service Class __________.0% Dreyfus Emerging Markets Portfolio - __________.0% Dreyfus Founders Passport Portfolio - Service Class Service Class __________.0% Dreyfus Founders Discovery Portfolio - __________.0% Dreyfus Growth and Income Portfolio - Service Class Service Class __________.0% Dreyfus Founders Growth Portfolio - __________.0% Dreyfus International Equity Portfolio - Service Class Service Class __________.0% Dreyfus Founders International Equity __________.0% Dreyfus International Value Portfolio - Portfolio - Service Class Service Class __________.0% Dreyfus Founders Passport Portfolio - __________.0% Dreyfus Japan Portfolio - Service Class Service Class __________.0% Dreyfus Growth and Income Portfolio - __________.0% Dreyfus Limited Term High Yield Portfolio - Service Class Service Class __________.0% Dreyfus International Equity Portfolio - __________.0% Dreyfus MidCap Stock Portfolio - Service Class Service Class __________.0% Dreyfus International Value Portfolio - __________.0% Dreyfus Money Market Portfolio Service Class __________.0% Dreyfus Japan Portfolio - Service Class __________.0% Dreyfus Quality Bond Portfolio - Service Class __________.0% Dreyfus Limited Term High Yield Portfolio - __________.0% Dreyfus Small Company Stock Portfolio - Service Class Service Class __________.0% Dreyfus MidCap Stock Portfolio - __________.0% Dreyfus Special Value Portfolio - Service Class Service Class __________.0% Dreyfus Money Market Portfolio __________.0% Dreyfus Stock Index Fund - Service Class __________.0% Dreyfus Quality Bond Portfolio - __________.0% Dreyfus Technology Growth Portfolio - Service Class Service Class __________.0% Dreyfus Small Company Stock Portfolio - __________.0% The Dreyfus Socially Responsible Growth Service Class Fund, Inc. - Service Class __________.0% Dreyfus Special Value Portfolio - __________.0% Transamerica Equity - Initial Class Service Class __________.0% Dreyfus Stock Index Fund - __________.0% ___________________________________________ Service Class __________.0% Dreyfus Technology Growth Portfolio - __________.0% ___________________________________________ Service Class __________.0% The Dreyfus Socially Responsible Growth Fund, __________.0% ___________________________________________ Inc. - Service Class __________.0% Transamerica Equity - Initial Class __________.0% ___________________________________________ __________.0% _______________________________________________ __________.0% _______________________________________________ __________.0% _______________________________________________ __________.0% _______________________________________________
VA-APP 05/03 12. ASSET REBALANCING 14. AGENT INFORMATION I elect to rebalance the variable subaccounts according to my Do you have any reason to believe the annuity applied for lump sum allocation using the frequency indicated below. will replace or change any existing annuity or life insurance? Does not include fixed accounts and not available with DCA. [_] No [_] Yes If you would like to rebalance to a mix other than the indicated Allocation of Purchase Payments, please complete the I HAVE REVIEWED THE APPLICANT'S EXISTING ANNUITY Optional Programs Form. COVERAGE AND FIND THIS COVERAGE IS SUITABLE FOR HIS/HER NEEDS. [_] Monthly [_] Quarterly [_] Semi-Annually [_] Annually 13. SIGNATURE(S) OF AUTHORIZATION ACCEPTANCE #1: Registered Rep/Licensed Agent [_] Check here if you want to be sent a copy of "Statement of Print First Name: ____________________________________ Additional Information." Last Name: ___________________________________________ Will this annuity replace or change any existing annuity or life insurance? [_] No [_] Yes (If yes, complete the Signature: X following) Rep Phone #: _________________________________________ Company: ___________________________________________________ Email Address (Optional): ____________________________ Policy No.: ________________________________________________ SSN/TIN: _____________________________________________ . Unless I have notified the Company of a community or marital property interest in this contract, the Company will rely on Florida Agent License # (FL only):____________________ good faith belief that no such interest exists and will assume no responsibility for inquiry. #2: Registered Rep/Licensed Agent . To the best of my knowledge and belief, my statements and Print First Name: ____________________________________ answers to the questions on this application are correct and true. Last Name: ___________________________________________ . I am in receipt of a current prospectus for this variable Signature: X annuity. Rep Phone #: _________________________________________ . This application is subject to acceptance by the Insurance Company. If this application is rejected for any reason, Email Address (optional): ____________________________ the Insurance Company will be liable only for return of purchase payment paid. SSN/TIN: _____________________________________________ . Florida Residents- Any person who knowingly and with intent Florida Agent License # (FLonly): ____________________ 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. Firm Name: _______________________________________________ . Account values when allocated to any of the subaccounts in Section 10 are not guaranteed as to fixed dollar amount. Firm Address: ____________________________________________ . For residents in all states except CT, MN, NJ, PA, VT, VA, For Registered Representative Use Only - Contact your home WA When funds are allocated to the Fixed Accounts in office for program information. Section 10, policy values may increase or decrease in accordance with an Excess Interest Adjustment prior to the [_] Option A [_] Option B [_] Option C [_] Option D end of the Guaranteed Period. (Once selected, program cannot be changed) I HAVE REVIEWED MY EXISTING ANNUITY COVERAGE REPLACEMENT INFORMATION AND FIND THIS COVERAGE SUITABLE FOR MY NEEDS. For applicants in Colorado, Hawaii, Iowa, Louisiana, Signed at: ___________________________________________________ Maryland, Mississippi, Montana, New Hampshire, City State Date North Carolina, Vermont Applicant: Owner(s) Signature: X 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 Joint Owner(s) Signature: X Annuities.") Agent: Did the agent/registered representative present and leave Annuitant Signature: (if not Owner) X the applicant insurer-approved sales material? [_] No [_] Yes
VA-APP 05/03 For Applicants in AZ For Applicants in KY, OH, OK Upon your written request, the Company is required to provide, Any person who knowingly and with intent to defraud any within a reasonable time, reasonable factual information insurance company or other person files an application for concerning the benefits and provisions of the contract to you. insurance or statement of claim containing any materially If for some reason you are not satisfied with the contract, false information or conceals for the purpose of misleading, you may return it within twenty days after it is delivered and information concerning any fact material thereto commits a receive a refund equal to the premiums paid, including any fraudulent insurance act, which is a crime. policy or contract fees or other charges, less the amounts allocated to any separate accounts under the policy or For Applicants in LA contract, plus the value of any separate accounts under the policy or contract on the date the returned policy is received Any person who knowingly presents a false or fraudulent by the insurer. claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty Annuity Commencement Date:________________________ Recommended of a crime and may be subject to fines and confinement in annuitant age 70 1/2 for qualified. prison. For Applicants in AR, NM, PA For Applicants in ME Any person who knowingly and with intent to defraud any Any person who, with the intent to defraud or knowing that insurance company or other person files an application for he is facilitating a fraud against an insurer, submits an insurance or statement of claim containing any materially application or files a claim containing a false or deceptive false information or conceals for the purpose of misleading, statement may have violated state law. information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects a For Applicants in NJ person to criminal and civil penalties. Any person who includes any false or misleading information For Applicants in CO on an application for an insurance policy is subject to criminal and civil penalties. It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for For Applicants in VA the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, and denial Any person who, with the intent to defraud or knowing that of insurance, and civil damages. Any insurance company or he is facilitating a fraud against an insurer, submits an agent or an insurance company who knowingly provides false, application or files a claim containing a false or deceptive incomplete, or misleading facts or information to the statement may have violated state law. This plan is intended policyholder or claimant for the purpose of defrauding or to qualify under the Internal Revenue Code for tax favored attempting to defraud the policyholder or claimant with regard status. Language contained in this policy referring to to a settlement or award payable from insurance proceeds shall Federal tax statutes or rules is informational and be reported to the Colorado Division of Insurance within the instructional and this language is not subject to approval Department of Regulatory Agencies. for delivery. Your qualifying status is the controlling factor as to whether your funds will receive tax favored For Applicants in DC, TN treatment rather than the insurance contract. Please ask your tax advisor if you have any questions as to whether or It is a crime to provide false or misleading information to an not you qualify. insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
VA-APP 05/03