MASTER APPLICATION FOR
GROUP VARIABLE FUNDING AGREEMENT
Application is hereby made for a Group Variable Funding Agreement (the
"Contract"):
1. Application-Contract Owner:
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Xxxxxx xx X.X. Xxx
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Xxxx Xxxxx Zip Code
2. Name of Applicant's Business:
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3. Requested Effective Date of Contract:
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4. Special Requests:
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5. The Contract Owner has elected (choose a method): / / METHOD ONE / / METHOD
TWO for the deduction of the Program and Administrative Charge and for the
determination of the Net Investment Factor under the Contract.
IT IS UNDERSTOOD THAT ALL PAYMENTS AND VALUES PROVIDED BY THE CONTRACT ARE THE
EXCLUSIVE PROPERTY OF THE APPLICANT-CONTRACT OWNER AND WHEN BASED ON THE
INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND NOT GUARANTEED AS
TO FIXED DOLLAR AMOUNT.
Dated at this day of
For
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(Contract Owner)
By
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Registered Representative
(Licensed Agent)
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(Title)
