EXHIBIT 99.5
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SPINNAKER-Registered Trademark- VARIABLE ANNUITY
[SAFECO LOGO] SPINNAKER-Registered Trademark- PLUS VARIABLE ANNUITY SAFECO Life Insurance Company
INDIVIDUAL DEFERRED VARIABLE ANNUITIES 0000 000xx Xxxxx XX
Xxxxxxx, XX 00000-0000
Telephone 0-000-000-0000
TTY/TDD 0-000-000-0000
MINIMUM INITIAL PURCHASE PAYMENT AMOUNTS
/ / SPINNAKER (FLEXIBLE PREMIUM) / / SPINNAKER PLUS (MODIFIED SINGLE PREMIUM)
Qualified - $30 Qualified & Non-Qualified - $50,000
Non-Qualified - $2,000 ($100 under Systematic Investing)
/ / SPINNAKER SELECT PROGRAM
Qualified & Non-Qualified - $10,000
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1. OWNER
INFORMATION Name__________________________________________________________________________________________________________
First Middle Last
Mailing Address_______________________________________________________________________________________________
Street City State Zip Code
Telephone (_____)________________________ Soc. Sec. #_____________________ Date of Birth______________________
Mo. Day Yr.
JOINT OWNER Name__________________________________________________________________________________________________________
(Non-Qualified First Middle Last
Only)
Mailing Address_______________________________________________________________________________________________
Street City State Zip Code
Telephone (_____)________________________ Soc. Sec. #_____________________ Date of Birth______________________
Mo. Day Yr.
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2. ANNUITANT
INFORMATION Name__________________________________________________________________________ / / Male / / Female
First Middle Last
(Non-Qualified
Only) Mailing Address_______________________________________________________________________________________________
Street City State Zip Code
Telephone (_____)________________________ Soc. Sec. #_____________________ Date of Birth______________________
Mo. Day Yr.
JOINT ANNUITANT Name__________________________________________________________________________ / / Male / / Female
First Middle Last
(Non-Qualified
Only) Mailing Address_______________________________________________________________________________________________
Street City State Zip Code
Telephone (_____)________________________ Soc. Sec. #_____________________ Date of Birth______________________
Mo. Day Yr.
IF NO ANNUITANT IS SPECIFIED, THE OWNER WILL BE THE ANNUITANT.
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3. TYPE OF ANNUITY / / TSA / / DEFERRAL TSA / / TRANSFER FROM ANOTHER TSA
/ / Transfer TSA was an Annuity under IRC 403(b)
/ / IRA / / INDIVIDUAL RETIREMENT ANNUITY (IRA)
/ / Contribution for calendar year _________ to a / / Regular IRA or / / Xxxx XXX
/ / Rollover* from a / / Regular IRA or / / Xxxx XXX
/ / Transfer* from a / / Regular IRA or / / Xxxx XXX
The taxable year for which I first made a Xxxx XXX contribution was __________.
/ / Convert my Regular IRA by rollover or transfer to a Xxxx XXX.
/ / Rollover* from a Qualified Retirement Plan or TSA
/ / SIMPLIFIED EMPLOYEE PENSION (SEP) IRA PLAN
/ / Salary Reduction (SARSEP). Only available if plan established prior to 1997.
/ / SAVINGS INCENTIVE MATCH PLAN FOR EMPLOYEES (SIMPLE) IRA
/ / Rollover* from a SIMPLE IRA Original date of SIMPLE IRA ____/____/_____
/ / NON-QUALIFIED ANNUITY / / 1035 Exchange.*
* MUST COMPLETE FORM LP-1185, ROLLOVER, TRANSFER, AND/OR EXCHANGE REQUEST.
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-Registered Trademark- A registered trademark of SAFECO Corporation
LPC-1089 3/99 -Registered Trademark- Spinnaker is a registered trademark of SAFECO Life Insurance Company
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4. BENEFICIARY
PRIMARY: Name ______________________________________________________________ Percentage____________%
(Please attach a First Middle Last
signed and dated Mailing Address___________________________________________________________________________________________
listing of any Street City State Zip Code
additional names.) Soc. Sec. #______________________________ Date of Birth______________________ / /Male / /Female
Mo. Day Yr.
Relationship to Owner_____________________________________________________________________________________
CONSENT OF SPOUSE REQUIRED FOR ERISA PLAN PARTICIPANT NAMING A NON-SPOUSE PRIMARY BENEFICIARY: I consent to
the above designation of Beneficiary. I understand that if anyone other than me is designated as Primary
Beneficiary on this form, I am waiving my right to receive benefits under the plan when my spouse dies.
Signature of Spouse________________________________________________________________ Date _______________
Mo. Day Yr.
/ / I am not married.
/ / PRIMARY
/ / CONTINGENT: Name____________________________________________________________ Percentage____________%
First Middle Last
Mailing Address___________________________________________________________________________________________
Street City State Zip Code
Soc. Sec. #______________________________ Date of Birth_______________________ / /Male / /Female
Mo. Day Yr.
Relationship to Owner______________________________________________________________________________________
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5. INVESTMENT
INSTRUCTIONS ____% SAFECO RST Bond ____% Federated High Income Bond Fund II
Choose one or more ____% SAFECO RST Equity ____% Federated Utility Fund II
of the following.
Whole percentages ____% SAFECO RST Growth Opportunities ____% Fidelity VIP Growth
only.
____% SAFECO RST Money Market ____% Fidelity VIP III Growth & Income
TOTAL OF ALL
PERCENTAGES MUST ____% SAFECO RST Northwest ____% Fidelity VIP III Growth Opportunities
EQUAL 100%.
____% SAFECO RST Small Company Value ____% Franklin Small Cap Fund - Class 2
____% AIM V.I. Aggressive Growth ____% Franklin U.S. Government Fund - Class 2
____% AIM V.I. Growth ____% INVESCO VIF-Real Estate Opportunity Fund
____% American Century VP Balanced ____% X.X. Xxxxxx U.S. Disciplined Equity
____% American Century VP International ____% Xxxxxxx VLIF Balanced
____% Dreyfus VIF Appreciation ____% Xxxxxxx VLIF International
____% Dreyfus IP MidCap Stock ____% Xxxxxxxxx Developing Markets Securities
Fund - Class 2
____% Dreyfus VIF Quality Bond
____% SAFECO Life Fixed Account
____% Dreyfus Socially Responsible Growth Fund,
Inc.
____% Dreyfus IP Technology Growth
Purchase Payments to the SAFECO Life Fixed Account will be allocated immediately upon receipt. Purchase
Payments to the variable Portfolios may be invested in the SAFECO RST Money Market Portfolio until the
expiration of 15 days from the date the first Purchase Payment is received, and then will be invested
according to your investment instructions.
If you selected the Spinnaker Select Program, 25% of each Purchase Payment must be allocated to the
Portfolios of your choice (other than the SAFECO RST Money Market Portfolio), or you must enroll in either
Dollar Cost Averaging or Interest Sweep (see Section 7 for additional details).
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6. SYSTEMATIC INVESTING / / I would like to make regular Purchase Payments from my checking or savings account. I have completed
Form LPS-5318 and am sending it in with this application. (Not available for TSA or 457 Plans.)
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7. SCHEDULED TRANSFERS / / I have read the information in the Prospectus about the following scheduled transfers and would like to
elect:
1. / / DOLLAR COST AVERAGING: I elect to transfer $______ (minimum $50, except for Spinnaker
Select*) or _________% from the _______________________________ Portfolio or
/ / Fixed Account / / monthly / / quarterly to the Portfolios listed below. * If selected as part
of the Spinnaker Select Program, monthly transfers must equal 1.33% of the value in the Fixed
Account as of the date the transfers begin and must continue for at least 36 months.
2. / / APPRECIATION OR INTEREST SWEEP ($10,000 minimum account balance required): I elect to have the
/ / appreciation of the Money Market Portfolio OR / / the interest earned on the Fixed Account
transferred / /monthly / /quarterly / /annually to the portfolios listed below. Appreciation
or Interest Sweep cannot be used to transfer money to the Fixed Account or to the SAFECO RST Money
Market Portfolio. If Interest Sweep is selected as part of the Spinnaker Select Program, monthly
transfers from the Fixed Account must continue for at least 36 months.
3. / / PORTFOLIO REBALANCING ($10,000 minimum account balance required): I elect to rebalance my Portfolios
/ / quarterly / / semiannually / / annually.
____% SAFECO RST Bond ____% Dreyfus IP Technology Growth
____% SAFECO RST Equity ____% Federated High Income Bond Fund II
____% SAFECO RST Growth Opportunities ____% Federated Utility Fund II
____% SAFECO RST Money Market ____% Fidelity VIP Growth
____% SAFECO RST Northwest ____% Fidelity VIP III Growth & Income
____% SAFECO RST Small Company Value ____% Fidelity VIP III Growth Opportunities
____% AIM V.I. Aggressive Growth ____% Franklin Small Cap Fund - Class 2
____% AIM V.I. Growth ____% Franklin U.S. Government Fund - Class 2
____% American Century VP Balanced ____% INVESCO VIF-Real Estate Opportunity Fund
____% American Century VP International ____% X.X. Xxxxxx U.S. Disciplined Equity
____% Dreyfus VIF Appreciation ____% Xxxxxxx VLIF Balanced
____% Dreyfus IP MidCap Stock ____% Xxxxxxx VLIF International
____% Dreyfus VIF Quality Bond ____% Xxxxxxxxx Developing Markets Securities
____% Dreyfus Socially Responsible Growth Fund, Fund - Class 2
Inc.
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8. TELEPHONE TRANSFER I, ___________________________________________ , hereby authorize SAFECO Life Insurance Company (SAFECO)
AUTHORIZATION to accept and act on telephone instructions from me or any person(s) listed below regarding the transfer
of funds between, or change in the percentage of my allocations among, portfolios of my variable annuity
contract. This authorization will remain in effect until SAFECO receives written revocation from me.
SAFECO will employ reasonable procedures to confirm that instructions communicated by telephone are
genuine. SAFECO reserves the right to refuse telephone instructions from any caller when unable to
confirm to SAFECO's satisfaction that the caller is authorized to give those instructions.
To transfer by telephone, call SAFECO at 1-877-4SAFECO (000-0000). All telephone transfer calls will be
recorded. You or your authorized third party will be required to provide the identification information
listed below. Written confirmation of transfer transaction(s) will be mailed to you.
Unless otherwise indicated, this form does not permit anyone else to exercise discretionary authority to
effect transactions on my behalf without obtaining my prior authorization. If you are unsure if you have
this authority, please consult your broker/dealer.
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PRINT OR TYPE FULL NAME OF AUTHORIZED THIRD PARTY
IDENTIFICATION INFORMATION:
My mother's maiden name is:__________________________________________ Account #_________________________
(if available)
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Signature of Owner/Participant Date
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9. TSA INFORMATION Employer Name ____________________________________________________________________________________________
Address___________________________________________________________________________________________________
Street City State Zip Code
Please verify that the TSA Plan Information Sheet is on file with the SAFECO Life Home Office. This
application cannot be processed without verification of Employer's eligibility to sponsor a 403(b) Plan.
PLANS COVERED BY XXXXX:
This employee has satisfied all eligibility requirements to receive contributions under our plan.
Furthermore, Joint & Survivor Annuity option disclaimers (if required by plan) are on file with
the Plan Administrator.
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Plan Administrator Signature Date
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10. STATEMENT OF HAVE YOU RECEIVED A CURRENT PROSPECTUS? / / YES / / NO
OWNER(S)
Will the annuity applied for here replace any annuity or life insurance from this or any other company?
/ / Yes / / No If yes, give policy number and full company name: Policy #:______________________
Company Name:_____________________________________________________________________________________________
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other
person files an application of insurance 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.
I declare that the statements and answers on this application are full, complete, and true, to the best
of my knowledge and belief, and shall form a part of the annuity contract issued hereon. I understand and
agree that any fees or taxes will be deducted from my Contract Value or Purchase Payment, as applicable.
I UNDERSTAND THAT VARIABLE BENEFITS AND CONTRACT VALUES ARE BASED ON INVESTMENT PERFORMANCE OF THE
SEPARATE ACCOUNT AND CANNOT BE PREDICTED OR GUARANTEED AS TO DOLLAR AMOUNTS. Variable annuity
contracts should be purchased for long-term retirement purposes.
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Signature of Owner Signed in City, State
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Signature of Joint Owner (if applicable) Date
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11. REGISTERED To the best of my knowledge, the annuity applied for here / / DOES / / DOES NOT replace any life
REPRESENTATIVE insurance or annuity in this or any other company. If it does, I have attached the required replacement
INFORMATION forms.
MAIL CONTRACT TO: Explanation of how this Contract serves the Owner's needs: ______________________________
/ / client ______________________________________________________________________________
/ / registered
representative's ------------------------------------------------------------------------------
office
I hereby certify that I witnessed the signature(s) above and that the answers to the questions above are
true to the best of my knowledge and belief.
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Registered Representative's Name Stat # %
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Registered Representative's Name Stat # %
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Agency State/Location ID #
___________________________________________________________ ( )____________________________
Registered Representative's Signature Telephone Number
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