Exhibit 5(b)
Enrollment/Change Request
& Salary Reduction Agreement-Variable Annuity
UNUM Life Insurance Company of America
Retirement Security Division - TSA/Client Services
X.X. Xxx 0000
Xxxxxxxx, Xxxxx 00000-0000
Tel. 0-000-000-0000
Fax 0-000-000-0000
[ ]New Enrollment
Check here to receive a Statement [ ]Change (Please indicate what type of
of Additional Information which change with a
provides financial information Address/Telephone Beneficiary Name
not included in the prospectus. Allocation Mix
I. Participant Information (please print)
Name of Employer GP/ER ID Number
Group Annuity Contract Numbers
Name of Employee: Last, First, MI Marital Status Social Security Number
Home Address (Street, City, State, Zip Code)
Telephone Number Date of Birth Sex Date of Hire
Daytime ( ) Evening
II. Salary Reduction Agreement (Annual)
Effective Date of Reduction Please check with your payroll department to
determine which option they are equipped to handle per pay period: Percentage of
pay or Specific dollar amount $
My employer and I hereby agree as follows: My employer shall reduce my salary by
the indicated amount/percentage per pay period. My employer shall forward such
amounts to an account with UNUM/America in order to fund contributions toward a
403(b) annuity. Reductions shall commence on the date indicated above.
Reductions shall only be made against sums earned by me subsequent to the date
of this agreement. Once made, this agreement cannot be changed for the rest of
the current tax year, although it may be canceled at any time. By signing below,
both my employer and I agree to be bound by the terms of this Salary Reduction
Agreement.
Participant's Signature Employer's Authorized Representative Signature
Complete the following in 1% increments
Fund Guar. Int
VA Product Assist Mgr. Social Res. Balanced Equity Inc. Index Acct.
GA ----------- ----------- --------- ---------- -----------
AM SR BL EQ IX
Growth I Growth II Int'nI. Small cap Total must
-------- --------- ------- ---------- equal 100%
GR GT IN SC
Allocation
Mix
Any change in allocation mix will be effective with the next deposit after
receipt of this form at UNUM's Home Office.
I am aware that the returns on the Variable Accounts will be based upon the
investment experience of VA-1 Separate Account. These amounts will fluctuate and
are not guaranteed as to the dollar amount.
Confirmations will bne generated once UNUM/America receives complete enrollment
information. Please review the confirmation carefully and notify UNUM/America
immediately if any changes are desired. Any changes to my name and/or
beneficiary designations must be in writing. I understand and agree that
UNUM/America may elect to send, directly to my employer, any confirmations of
transactions relating to my account.
Ill. Beneficiary Designation
If I am married or am subsequently married in the future and if my TSA Plan
provides, my spouse shall be my beneficiary unless I complete a waiver with my
spouse's written consent. I also understand that if I do not select a
beneficiary or if I am not survived by any beneficiary that all death benefits
will be paid in accordance with the Plan or contract provisions governing such
situations. Subject to the provisions of the above contract and any applicable
TSA Plan, I designate the following beneficiary(is), such designation to
supersede any prior designation(s) which I may have made with respect to my
coverage under the above contract. (Prim. - Primary Cant. - Contingent)
Beneficiary Name Address Relationship Percent
Prim. Cont.
[ ] [ ]
[ ] [ ]
[ ] [ ]
Prim. - Primary Cont. - Contingent
I acknowledge receipt of the VA-1 Separate Account prospectus and prospectuses
for the underlying funds and an Active Life Certificate. By completing and
signing this form, I also acknowledge that I have read and understand the
Information on the front and back of this form.
Participant's Signature Date
I hereby certify that the above referenced Participant's beneficiary designation
Is In compliance with all provisions of the Retirement Equity Act of 1984 and
the Tax Deferred Annuity Plan referenced above.
Plan Administrator's Signature (if ERISA) Date
L1 282-94(10/96) Enrollment
White copy to address above, Canary to Payroll Department, Pink to Broker,
Yellow to Participant (See Reverse Side)
Variable Annuity - An Investment For Your Future
As an investor in the UNUM/America Variable Annuity I have read the prospectus
for the Variable Annuity. Also, I have read the fund prospectus that supports
any Variable Account that I selected. I understand that the funds supporting the
UNUM/America's Variable Annuity are not public funds and are only available
through insurance company contracts.
I understand the fund "Investment Objectives and Policies" which are stated in
the fund prospectus. Generally, the greater an investment's possible reward over
time, the greater its level of short-term price volatility or risk. Thus, If my
retirement date is approaching or if I expect to request a withdrawal soon, I
may wish to select investments that are less risky.
My investment goals may change as I near retirement or if I have a lifestyle
change. On a regular basis I should review my investment selections in the
UNUM/America Variable Annuity. As part of this review, I should read current
fund prospectuses and financial reports. I understand I may contact UNUM/America
anytime to receive up-to-date information about my UNUM/America Variable
Annuity.
Restriction of Withdrawals
I understand that withdrawals are restricted to the requirements of Section
403(b) of the Internal Revenue Code which are described in the current VA-1
Separate Account prospectus. Withdrawals must also be in accordance with any
restrictions set forth in the TSA Plan sponsored by my employer.
Pending Allocation Account
I understand that if my contributions are received at UNUM/America without the
complete and accurate information needed to allocate my contributions they will
be allocated to the Pending Allocation Account. Once the information is
received, UNUM/America will allocate my contribution as I have indicated on the
form. After the third monthly notice, if UNUM/America has not received this
information, the account value will be returned to my contractholder.
Transfer Assets
I understand that if I transfer any assets to UNUM/America without an
accompanying Transfer Form indicating my investment allocation split,
UNUM/America will deposit these transfer assets in accordance with my most
recent investment elections on file.
Beneficiary Designation Instructions
1. The full name, address, and relationship to the Participant of each
beneficiary should be shown.
2. Indicate for each beneficiary whether he/she is a primary or a contingent
beneficiary.
- A primary beneficiary will be entitled to the entire value of the account.
- Multiple surviving primary beneficiaries will be entitled to equal
portions of the account, unless otherwise specified.
- A contingent beneficiary will be entitled to the entire value of the
account if the primary beneficiary (beneficiaries) is not living.
- Multiple surviving contingent beneficiaries will be entitled to equal
portions of the account, unless otherwise specified, If the primary
beneficiary (beneficiaries) is not living.
3. If I require more space to list my beneficiary designations, I will provide
all the required information on a separate page and attach.
