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Exhibit 5
PROVIDENT MUTUAL LIFE INSURANCE COMPANY PC 0103
P.O. Box 15750, Wilmington, DE 19850-5750
1. PRODUCT:_____________________________________________________
2. ANNUITANT INFORMATION
_____________________________________________________________
First Name MI Last Name
_____________________________________________________________
Street Address
_____________________________________________________________
City State Zip Code
_____________________________________________________________
Date of Birth [ ]Male [ ]Female
_____________________________________________________________
Social Security Daytime Phone Number
_____________________________________________________________
E-mail Address
3. BENEFICIARY INFORMATION
_____________________________________________________________
Name of Primary Relationship to Owner
_____________________________________________________________
Name of Contingent Relationship to Owner
IF A TRUST, COMPLETE BELOW:
_____________________________________________________________
Name Date Trustee's Name
4. OWNER INFORMATION (if other than Annuitant)
_____________________________________________________________
First Name/Name of Trust MI Last Name
_____________________________________________________________
Street Address
_____________________________________________________________
City State Zip Code
_____________________________________________________________
E-mail Address
_____________________________________________________________
Date of Birth/Trust S.S./Tax I.D. Number Daytime Phone Number
[ ] Joint Owner (must be spouse of Owner)
_____________________________________________________________
Name
_____________________________________________________________
Date of Birth Social Security Number
5. TYPE OF ANNUITY (complete A or B)
A. NON-QUALIFIED (choose one)
[ ] Non-Qualified [ ] 1035 Exchange
[ ] Transfer (CD, Mutual
Funds, etc.)
B. QUALIFIED (choose one)
[ ] IRA Rollover [ ] 403(b) Transfer
[ ] IRA Transfer [ ] HR10/Xxxxx
[ ] SIMPLE IRA [ ] Profit Sharing*
[ ] SEP IRA [ ] Pension*
[ ] Xxxx Conversion IRA *(Plan Year End________________)
Month, Day, Year
6. RIDERS
Step Up Death Benefit (available for Issue Ages 0-70 only).
[ ] Charitable Remainder Trust ($100,000 minimum)
7. PREMIUM PAYMENT
a. Initial premium payment: $_________________________________
b. Subsequent premium amounts: $______________________________
[ ] Annually [ ] Semiannually [ ] Quarterly
[ ] APP (submit completed authorization and voided check)
8. AUTOMATIC ASSET REBALANCING
The Owner may authorize periodic transfers of amounts among the Subaccounts
in order to achieve a particular percentage allocation among Subaccounts. No
amounts will be transferred to or from the Guaranteed Account under this
feature.
[ ] I elect Automatic Asset Rebalancing of the variable subaccounts to the
premium allocations specified in Question 11.
[ ] Annually [ ] Quarterly
PROVIDENT MUTUAL LIFE INSURANCE COMPANY PC 0103
P.O. Box 15750, Wilmington, DE 19850-5750
9. DOLLAR COST AVERAGING
The Owner may elect to systematically and automatically transfer, on a
monthly basis, specified dollar amounts from a designated Subaccount(s) or
Guaranteed Account to other Subaccount(s).
Transfer $________________ each month ($500 minimum) from the ____________
Subaccount to the Subaccount(s) designated in Question 11 over:
[ ] 6 months [ ] 18 months [ ] 30 months
[ ] 12 months [ ] 24 months [ ] 36 months
10. EARNINGS SWEEP
The Owner may elect to move Monthly earnings form the Money Market or
Guaranteed Account to a specified Subaccount(s).
Transfer all earnings from the [ ] Money Market or [ ] Guaranteed Account
(excluding the DCA Guaranteed Account) on a monthly basis to the Earnings
Sweep allocations selected in Question 11.
11. INITIAL ALLOCATION (whole percentages)
DCA OR
PREMIUMS EARNINGS SWEEP
MARKET STREET INVESTMENT MGMT.
All Pro Large Cap Growth............. ____ % _________ %
All Pro Large Cap Value.............. ____ % _________ %
All Pro Small Cap Growth............. ____ % _________ %
All Pro Small Cap Value.............. ____ % _________ %
All Pro Broad Equity................. ____ % _________ %
Mid Cap Growth....................... ____ % _________ %
Bond................................. ____ % _________ %
Balanced............................. ____ % _________ %
Money Market......................... ____ % _________ %
STATE STREET GLOBAL ADVISORS
Equity 500 Index..................... ____ % _________ %
THE BOSTON CO. ASSET MGMT.
International........................ ____ % _________ %
FIDELITY MGMT. & RESEARCH
Contrafund........................... ____ % _________ %
Growth............................... ____ % _________ %
Growth Opportunities................. ____ % _________ %
Overseas............................. ____ % _________ %
MFS INVESTMENT MANAGEMENT
Emerging Growth Series............... ____ % _________ %
Investor's Trust Series.............. ____ % _________ %
New Discovery Series................. ____ % _________ %
Research Series...................... ____ % _________ %
OPCAP ADVISORS
Equity............................... ____ % _________ %
Managed.............................. ____ % _________ %
PIMCO
High Yield........................... ____ % _________ %
Total Return......................... ____ % _________ %
STRONG CAPITAL MANAGEMENT
Mid Cap Growth Fund II............... ____ % _________ %
Opportunity Fund II.................. ____ % _________ %
XXX XXX ASSOCIATES
Worldwide Bond....................... ____ % _________ %
Worldwide Emerging Markets........... ____ % _________ %
Worldwide Hard Assets................ ____ % _________ %
Worldwide Real Estate................ ____ % _________ %
GUARANTEED ACCOUNT ____ % N/A
Only one transfer out of the Guaranteed Account allowed each year. This
transfer must be requested within 30 days before and 30 days after the Contract
Anniversary. Any unused transfer does not carry over the next year. The
maximum transfer amount from the Guaranteed Account is 25% of the Guaranteed
Account Value on the date of transfer, unless the balance after the transfer is
less than $500.00.
DCA GUARANTEED ACCOUNT - VIP
Premium Only
6-Month................................ ____ % N/A
12-Month............................... ____ % N/A
_______________________________________________________________________________
PMA18 1.00 (Rev. 5.01)
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12. SYSTEMATIC WITHDRAWAL PLAN
The Owner may elect to systematically and automatically receive withdrawals on
a monthly or a quarterly basis. Systematic withdrawals cannot be used to
continue the contract in force beyond the Maturity Date. On the Maturity Date
the contract must annuitize.
Please withdraw $_____________ (minimum $100 per month or $300 per quarter) on
a / / monthly or / / quarterly basis.
/ / I DO NOT want federal income tax withheld from the distribution.
/ / I DO want federal income tax withheld from the distribution at a rate of
________% (not less than 10%).
13. REPLACEMENT
Will the proposed contract replace or change any existing annuity contract or
insurance policy? / / Yes / / No
(If yes, list company name, contract/policy number and year of issue.)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
14. SIGNATURE(S)
I (we) represent that my (our) answers to the above questions are correct and
true to the best of my (our) knowledge, information and belief and agree that
this application shall be a part of any annuity contract issued by the Company.
I (we) acknowledge receipt of a current prospectus describing the contract
applied for and the underlying Subaccounts elected in Question 11. I (WE)
UNDERSTAND THAT THE CONTRACT ACCOUNT VALUES AND SURRENDER VALUES UNDER ANY
CONTRACT ISSUED PURSUANT TO THIS APPLICATION, WHEN BASED UPON ASSETS ALLOCATED
TO THE PROVIDENT MUTUAL VARIABLE ANNUITY SEPARATE ACCOUNT, ARE VARIABLE IN
NATURE AND ARE NOT GUARANTEED AS TO THEIR DOLLAR AMOUNT BY THE COMPANY OR ANY
OTHER INSURANCE COMPANY, ARE NOT GUARANTEED BY THE U.S. GOVERNMENT OR ANY STATE
GOVERNMENT, AND ARE NOT FEDERALLY INSURED BY THE FDIC, THE FEDERAL RESERVE
BOARD OR ANY OTHER FEDERAL OR STATE AGENCY. THE CONTRACT I (WE) HAVE APPLIED
FOR IS SUITABLE FOR MY (OUR) INSURANCE INVESTMENT OBJECTIVES, FINANCIAL
SITUATION AND NEEDS.
I (we) hereby certify, under penalties of perjury, that the social security
number and taxpayer identification number I (we) am (are) providing is correct
and I (we) am (are) neither currently subject to backup withholding, nor have
been so notified by the Internal Revenue Service.
Signed at ___________________________________________________________________
City State
On (Date) ___________________________________________________________________
Signature of Annuitant
(if other than Owner) _______________________________________________________
Signature of Owner
(if other than Annuitant) ___________________________________________________
Signature of Joint
Owner (if applicable) _______________________________________________________
FOR REGISTERED REPRESENTATIVE ONLY
Do you have knowledge or reason to believe that a replacement or change of
existing insurance or annuities may be involved?
/ / Yes (provide details in remarks) / / No
If the annuity now applied for is intended to replace or change insurance or
annuities in this or any other company, have you submitted to the applicant a
written proposal setting forth all the facts, advantages and disadvantages in
making this replacement?
/ / Yes (provide details in remarks) / / No
Is this transaction a 1035 exchange?
/ / Yes (provide details in remarks) / / No
Have you completed the state replacement form(s) (where required)?
/ / Enclosed / / Not Required
I have read the Insurance Company's statement regarding the appropriateness of
replacement transactions and believe this to be an appropriate replacement. I
have used only Company approved sales materials in connection with this
application, which are identified as follows:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
A copy of all sales material, other than the electronically presented sales
material, was left with the applicant on or before the application was
completed.
I have truly and accurately recorded all Applicant's answers on this application
and have witnessed his/her/their signature(s) hereon. I have reasonable grounds
to believe that the purchase of the contract applied for is suitable for the
Applicant.
Print Representative's Name ____________________________________________________
Signature of Representative ____________________________________________________
Date _____________________ Telephone No. _______________________________________
Print Name of Broker/Dealer ____________________________________________________
Authorized Signature _____________________________________ Date ________________
Representative(s) of Credit - Print Name % F.E. Code
________________________________________________________________________________
Name
____________________________________________
E-mail Address
________________________________________________________________________________
Name
____________________________________________
E-mail Address
________________________________________________________________________________
Name
____________________________________________
E-mail Address
COMMISSION OPTIONS (SELECT ONE)
/ / A - No Trails / / Trail Option B / / Trail Option C
PAYMENT INSTRUCTIONS
Make payments to "Provident Mutual Life Insurance Company."
REMARKS OR SPECIAL INSTRUCTIONS
