EXHIBIT 5
C.M. LIFE INSURANCE COMPANY Contract # ___________
000 Xxxxxx Xxxxxx (For H.O. Use
Xxxxxxxx, XX 00000 Only)
VARIABLE ANNUITY CONTRACT APPLICATION
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1. CONTRACT OWNER INFORMATION NOTE: Contract Owner must be same as Annuitant for all
types of IRAs and 403(b) plans.
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Name (First, MI, Last) Tax I.D./Social Security #
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Address (No., Street) Birth Date (Mo/Day/Yr)
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Address (City, State, Zip) Sex: [_] Male [_] Female Telephone Number
( )
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2. JOINT CONTRACT OWNER INFORMATION NOTE: .Joint ownership only allowed between spouses.
.Unless otherwise specified, both signatures
will be required for all Contract Owner
transactions.
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Name (First, MI, Last) Social Security #
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Address (No., Street) Birth Date (Mo/Day/Yr)
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Address (City, State, Zip) Sex: [_] Male [_] Female Telephone Number
( )
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3. ANNUITANT INFORMATION NOTE: .Add Annuitant information only if different from
Contract Owner.
.For additional instructions use Item 11.
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Name (First, MI, Last) Tax I.D./Social Security #
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Address (No., Street) Birth Date (Mo/Day/Yr)
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Address (City, State, Zip) Sex: [_] Male [_] Female Telephone Number
( )
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4. BENEFICIARY INFORMATION NOTE: .In the event of the death of a Joint Contract Owner,
the surviving spouse shall become the Primary
Beneficiary.
.For additional instructions use Item 11.
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Primary Beneficiary: Relationship to
Name (First, MI, Last) Contract Owner Tax I.D./Social Security #
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Address (No., Street) Birth Date (Mo/Day/Yr) Telephone Number
( )
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Address (City, State, Zip)
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Contingent Beneficiary: Relationship to Tax I.D./Social Security #
Name (First, MI, Last) Contract Owner
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Xxxxxxx (Xx., Xxxxxx) Birth Date (Mo/Day/Yr) Telephone Number
( )
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Address (City, State, Zip)
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5. PLAN INFORMATION
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Non-Qualified Plan: [_] Individual Plan
Qualified Plan: [_] Regular XXX--Tax year(s) _____, _____
[_] XXX Rollover/Transfer
[_] SEP-XXX
[_] Xxxx XXX
[_] 457 Deferred Compensation Plan
[_] TSA Plan (check one): Regular _____ Transfer _____
[_] Corporate, Plan Type Plan _____________________________
[_] Other _________________________________________________
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6. INITIAL PURCHASE PAYMENT $ _______
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7. HEALTH INFORMATION
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Do you have any reason to believe that the Death Benefit will become payable
to the Beneficiary in the first Contract Year? Yes [_] No [_]
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8. ANNUITY ACTIVITY
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.Have you purchased another Connecticut Mutual Life or C.M. Life Annuity in
the past 12 months? Yes [_] No [_]
.Will the annuity applied for replace or change any existing individual or
group life insurance or annuity? Yes [_] No [_]
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NOTE: .The Annuity Date must be the first
day of a calendar month.
9. ANNUITY DATE_____________ .The Annuity Date cannot be later
(Mo/Day/Yr) than the earlier of the Annuitant's
100th birthday or the maximum date
permitted under state law.
.If no election is made, the Annuity
Date will be the earlier of the
Annuitant's 100th birthday or the
maximum date permitted under state law.
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10. ANNUITY OPTIONS NOTE: .If no election is made 30 days before the Annuity
Date, payments will be made under Option B with a
10 Year Period Certain.
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[_] Option A--Life Income
[_] Option B--Life Income with Period Certain: [_] 5 Yr. [_] 10 Yr. [_] 20 Yr.
[_] Option C--Joint and Last Survivor
[_] Option D--Joint and 2/3 Survivor
[_] Option E--Period Certain: # of Years______
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11. MISCELLANEOUS INSTRUCTIONS/COMMENTS
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12. CONTRACT OWNER AND ANNUITANT SIGNATURES
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I hereby represent that the above information is correct and true to the best
of my knowledge and belief and agree that this application shall be a part of
the Contract issued by the Company. Any person who, with the intent to defraud
or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is
guilty of insurance fraud. ALL PAYMENTS AND VALUES PROVIDED BY THE CONTRACT
BEING APPLIED FOR WHEN BASED ON INVESTMENT EXPERIENCE OF A VARIABLE ACCOUNT
ARE VARIABLE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. I acknowledge receipt
of a current prospectus for the Contract.
Signed at: ________________________ ________ On:____/___/____
City State (Mo/Day/Yr)
Contract Owner Signature ___________________________________________________
Joint Contract Owner Signature _____________________________________________
Annuitant Signature (If other than a Contract Owner)________________________
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13. NASD REGISTERED REPRESENTATIVE/AGENT/BROKER INFORMATION
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Will the annuity applied for replace or change any existing individual or
group life insurance or annuity? If yes, I have complied with all state
replacement requirements. Yes [_] No [_]
Is this replacement meant to be a tax-free exchange under Section 1035?
Yes [_] No [_]
I certify that I am NASD registered and state licensed for variable annuity
contracts where this application is written and delivered.
Signature of NASD Registered
Representative/Agent/Broker__________________ Phone Number ( )_____________
Print Name and License #/Code________________________________________________
Name and Address of Firm_____________________________________________________
City______________________________________ State_______ Zip_______
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Make check(s) payable to C.M. Life and mail this signed Application and the
check to: C.M. Life Insurance Company
Annuity Service Center, H565
P. O. Xxx 0000
Xxxxxxxxxxx, XX 00000-0000
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