Exhibit 5.1
Individual Variable Annuity Application Contract#:_______________________
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1. INSURANCE COMPANY NAME and PRODUCT TYPE
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Federal Xxxxxx Life Assurance Company - Flexible Premium Fixed and Variable Deferred Annuity
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2. OWNER and ANNUITANT INFORMATION
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(select one) (_) Owner and Annuitant or (_) Trust
Name Daytime Phone Number Social Security Number Age
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( )
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Residence (no. P.O. Boxes) City State Zip Code Date of Birth (mm/dd/yyyy)
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Mailing Address (if different from above: P.O. Boxes may be used) City State Zip Code
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Sex (select one) Citizenship Status (select one) Country Country
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(_) Male (_) Female (_) USA (_) Resident Alien (_) Non-Resident Alien
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(select one) (_) Joint Owner (must be spouse) (non-qualified only) or (_) Annuitant (Specify only if Trust owned)
Name Daytime Phone Number Social Security Number Age
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( )
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Address City State Zip Code Date of Birth (mm/dd/yyyy)
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Sex (select one) Citizenship Status (select one) Country Country
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(_) Male (_) Female (_) USA (_) Resident Alien (_) Non-Resident Alien
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3. BENEFICIARY DESIGNATION (_) Additional Beneficiaries
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(See General Information item #6 on the back of this form regarding Joint Owners) Relationship to owner Social Security Number
Name Percentage -------------------------
(_) Primary -------------------------------- ------------------- (_) Spouse
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(_) Contingent -------------------------------- ------------------- (_) Non-spouse Date of Birth (mm/dd/yyyy)
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4. INITIAL PREMIUM AMOUNT
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(check payable to Federal Xxxxxx Life Assurance Company) Annuity Commencement Date
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$ (_) With Funds
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(_) Funds Will Follow (See General Information Item #7)
Tax Qualified Status: (select all that apply)
(_) Non-Qualified (_) Traditional IRA (_) Xxxx XXX (Conversion Year _____, if applicable) (_) Other _______________________
(_) 1035 Exchange Contribution for tax year_______ Trustee transfer Rollover from ______________________
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$ $ $
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5. ASSET ALLOCATION MODELS
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(select and complete 5. or 6., but not both)
(check one model only; asset allocation percentages shown directly below)
(_) Conservative Growth Model (_) Balanced Model (_) Growth & Income Model (_) Growth Model
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Asset Allocation Percentages For Each Model
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Conservative Balanced Growth & Growth
Growth Model Model Income Model Model
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One Group(R) Investment Trust:
Balanced Portfolio 0% 5% 5% 0%
Bond Portfolio 35% 24% 14% 5%
Diversified Equity Portfolio 14% 13% 16% 22%
Diversified Mid Cap Portfolio 0% 0% 9% 14%
Equity Index Portfolio 7% 11% 12% 13%
Government Bond Portfolio 35% 24% 14% 5%
Large Cap Growth Portfolio 3% 5% 8% 11%
Mid Cap Growth Portfolio 2% 7% 7% 10%
Mid Cap Value Portfolio 4% 11% 15% 20%
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Total 100% 100% 100% 100%
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See Reverse Side For General Information
Page 1 of 2
6. SELF-DIRECTED (Do not complete if Section 5 is completed)
(whole percentage only; A, B, and C must total 100%)
A. One Group Investment Trust: ___% Equity Index Portfolio X. Xxxxxxx Variable Investment Fund:
___% Balanced Portfolio ___% Gov't Bond Portfolio ___% Dreyfus Money Market
___% Bond Portfolio ___% Large Cap Growth Portfolio
___% Diversified Equity Portfolio ___% Mid Cap Growth Portfolio C. Dollar Cost Averaging Account:
___% Diversified Mid Cap Portfolio ___% Mid Cap Value Portfolio ___% Fixed Account
7. REPLACEMENT
Do you have any existing annuity contracts or life insurance policies?
(_) Yes (_) No
Will or may any existing life insurance or annuity be replaced or will values
from another insurance policy or annuity (through loans, surrenders or
otherwise) be used to pay premiums for the policy applied for? (_) Yes (_) No
______________________________
If yes, indicate company name and policy number: ______________________________
8. CONSENT TO ELECTRONIC DELIVERY
(_) I agree to have prospectus updates, semi-annual reports, proxy solicitation
material and other applicable regulatory documents delivered to me on an IBM and
Macintosh compatible CD-Rom. I understand that I may change my mind and choose
to receive paper copies of applicable regulatory documents by calling (888)
000-0000.
If you do not check the box above, you will receive paper copies of all required
regulatory documents. You will not receive electronic copies in addition to
paper copies provided.
9. OWNER SIGNATURES
RECEIPT IS ACKNOWLEDGED OF THE CURRENT PROSPECTUSES FOR THIS VARIABLE ANNUITY
AND THE UNDERLYING SUBACCOUNTS. PAYMENTS AND VALUES PROVIDED BY THE CONTRACT,
WHEN BASED ON INVESTMENT EXPERIENCE OF THE SUBACCOUNTS, ARE VARIABLE AND ARE NOT
GUARANTEED AS TO DOLLAR AMOUNT AND MAY INCREASE OR DECREASE. THEY ARE NOT
GUARANTEED BY THE COMPANY, ANY OTHER INSURANCE COMPANY, THE US GOVERNMENT OR ANY
STATE GOVERNMENT, AND ARE NOT INSURED BY THE FDIC, THE FEDERAL RESERVE BOARD OR
ANY OTHER FEDERAL OR STATE AGENCY. ALL RISK IS BORNE BY THE OWNER FOR THOSE
FUNDS ASSIGNED TO A SEPARATE ACCOUNT.
The models listed in section five above are general asset mixes. The models were
developed by Banc One Investment Advisors Corporation and may or may not be
appropriate for you. Banc One Investment Advisors Corporation serves as advisor
to the One Group Investment Trust Portfolios for which it receives a fee. There
is no guarantee that the models will achieve any desired results or objectives.
I understand that Banc One Investment Advisors Corporation is not providing
investment advice or any other service to me and that I am solely responsible
for determining whether a model is right for me. The models should not be
considered personal investment advice or serve as the sole or primary basis for
making investment decisions. Purchase payments and exchanges allocated to an
investment model will be invested in each underlying investment option at the
percentages set forth above.
Each investment allocation model automatically allocates a portion of my annuity
to certain subaccounts. Each model will be automatically rebalanced once each
year and upon changes to the models (as discussed on the back of this form).
Automatically rebalancing a model may involve transferring amounts from
subaccounts with higher returns into subaccounts with relatively lower returns
in order to maintain the percentages as set forth above. Transfers made as a
result of automatic rebalancing are not counted against my free transfers (in
the event transfer fees are imposed in the future). Automatic rebalancing ends
upon the termination of a model (when a model terminates is discussed on the
back of this form).
I understand that the underlying investment options described above are NOT
available to the general public directly. They are only available as Investment
options in variable life insurance policies or variable annuity contracts issued
by life insurance companies or, in some cases, through participation in certain
qualified pension or retirement plans.
(_) Please send me a copy of the Statement of Additional Information to the
prospectus.
I/We have read, agree to and affirm the information above and on the following
pages. Signed at:
City State Date (mm/dd/yyyy)
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Owner Name (printed) Owner Signature Social Security Number
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X
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Joint Owner Name (printed) Joint Owner Signature
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X
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10. SELLING AGENT REPORT
Does the applicant have any existing annuity contracts or life insurance
policies? (_) Yes (_) No
To the best of your knowledge, will or may any existing life insurance policy or
annuity contract be replaced or will values from another insurance policy or
annuity contract (through loans, surrenders, or otherwise) be used to pay
premiums for the contract applied for? (_) Yes (_) No
Agent Name (printed) Agent Signature Agent License Number (FL Only) or Rep. Number Agent's Phone No.
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( )
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Standard ID Date (mm/dd/yyyy)
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By:
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Page 2 of 2
[Product Name]
Insurance Company Address:
Federal Xxxxxx Life Assurance Company - 0000 XxXxxxxx Xxxxxxx, Xxxxxxxxxx,
Xxxxxxxx 00000-0000
Insurance Company Address:
Federal Xxxxxx Life Assurance Company - 0000 XxXxxxxx Xxxxxxx, Xxxxxxxxxx,
Xxxxxxxx 00000-0000
Warnings, Notices and Statements
For Arizona Applicants: Upon your written request, the insurance company is
required to provide, within a reasonable time, reasonable factual information
concerning the benefits and provisions of the annuity contract to you. If for
any reason you are not satisfied with the contract, you may return it within ten
days after it is delivered (30 days if the contract is issued in replacement of
an existing contract, or if you are 65 years of age or older). Upon such return,
you will receive a refund equal to the premiums paid, including any policy or
contract fees or other charges, less the amounts allocated to any separate
accounts under the policy or contract, plus the value of any separate accounts
under the policy or contract, within 10 days following our receipt of the
contract.
Arkansas, Colorado, District of Columbia, Kentucky, Louisiana, Maine, New
Mexico, Ohio, Oklahoma, Pennsylvania and Tennessee Fraud Warning - Any person
who knowingly and with intent to defraud any insurance company or other person,
files an application for insurance or statement of claim 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 and subjects such person to criminal and civil penalties.
FLORIDA FRAUD WARNING - ANY PERSON WHO KNOWINGLY AND WITH INTENT 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.
Michigan Fraud Warning - Any person who submits an application or files a claim
with intent to defraud or helps commit a fraud against an insurer, as determined
by a court of competent jurisdiction, is guilty of a crime.
New Jersey Fraud Warning - Any person who includes any false or misleading
information on an application for an insurance policy is subject to criminal and
civil penalties.
GENERAL INFORMATION
1. The Owner understands that when this application, in good order, and
payment are submitted, the Owner will be entitled to the benefits and bound
by the provisions of the insurance company contract. Application is subject
to acceptance by the issuing insurance company.
2. Under this contract the Owner(s) and Annuitant(s) are the persons
designated on this application unless the insurance company receives a
written request for a change.
3. The insurance company will not be liable for any loss, liability, cost, or
expense, for acting in accordance with instructions of the Owner or Joint
Owner.
4. The applicant, by signing the opposite side of this application, agrees to
the following statement: I HAVE REVIEWED MY EXISTING ANNUITY COVERAGE AND
FIND THIS CONTRACT IS SUITABLE FOR MY NEEDS.
5. The agent, by signing the opposite side of this application, agrees to the
following statement: I HAVE REVIEWED THE APPLICANT'S EXISTING ANNUITY
COVERAGE AND FIND THIS CONTRACT IS SUITABLE FOR HIS/HER NEEDS.
6. If you designate a joint Owner DO NOT name a primary beneficiary in the
Beneficiary Designation section. The surviving Joint Owner will be the
primary beneficiary upon the death of a Joint Owner.
7. The Annuity Date can not be later than the later of the contract
anniversary following the 90th birthday of the oldest Owner or Annuitant
initially designated or the 10th contract anniversary. If no annuity date
is selected by the Owner, the annuity date will be the later of the
contract anniversary following the 85th birthday of the oldest Owner or
Annuitant initially designated or the 5th contract anniversary.
Termination of a Model - I can stop using (i.e., terminate) a model at any time
by notifying the insurance company.
Changes to the Models - From time-to-time, Banc One Investment Advisors
Corporation may change the strategies used in an investment allocation model.
For example, it may change the percentages allocated to the available underlying
investment options within a model or it may change the underlying investment
options available for allocation within a model. However, such changes will not
impact a model's investment objective. Such changes in strategy may be made
without prior notice to you. However, as with other transfers of contract value
within your annuity, you will receive a confirmation statement when changes in
strategy result in the transfer of contract value between subaccounts.
