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Spinnaker(r) Advisor Variable Annuity SAFECO Life Insurance Company
[SAFECO logo] Individual Deferred Variable Annuity Application 0000 000xx Xxxxx XX
Xxxxxxx, XX 00000-0000
Telephone 1-800-4SAFECO
TTY/TDD 0-000-000-0000
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MINIMUM PURCHASE PAYMENT AMOUNTS
Initial Purchase Payment: $10,000
Minimum Allocations to the Fixed Account Options:
Dollar Cost Averaging (DCA) Fixed Account Option: $5,000
Enhanced Fixed Account Option: No minimum
Guaranteed Interest Period Fixed Account Option: $1,000 for each selected Guaranteed Period
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1. Owner
Information Name____________________________________________________________________________________________________
First Middle Last
Mailing Address__________________________________________________________________________________________
Street City State Zip Code
Telephone (_____)__________________________ Soc. Sec. #______________________ Date of Birth____________
Joint Owner Mo. Day Yr.
(Non-Qualified Only)
Name____________________________________________________________________________________________________
First Middle Last
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.
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)
[] XXX [] Individual Retirement Annuity (XXX)
[] Contribution for calendar year _________ to a [] Regular XXX or [] Xxxx XXX
[] Rollover* from a [] Regular XXX or [] Xxxx XXX
[] Transfer* from a [] Regular XXX or [] Xxxx XXX
The taxable year for which I first made a Xxxx XXX contribution was ________.
[] Convert my Regular XXX by rollover or transfer to a Xxxx XXX.
[] Rollover* from a Qualified Retirement Plan or TSA
[] Simplified Employee Pension (SEP) XXX Plan
[] Salary Reduction (SARSEP). Only available if plan established prior to 1997.
[] Savings Incentive Match Plan for Employees (SIMPLE) XXX
[] Rollover* from a SIMPLE IRAOriginal date of SIMPLE XXX ___/___/_____
[] Non-Qualified Annuity [] 1035 Exchange.*
* Must complete Form LP-1185, Rollover, Transfer, and/or Exchange Request.
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4. Beneficiary Primary: Name ___________________________________________________________________ Percentage_____%
First Middle Last
(Please attach a Mailing Address_________________________________________________________________________________________
signed and dated Street City State Zip Code
listing of any Soc. Sec. #______________________________________ Date of Birth______________________Male Female
additional names.) Mo. Day Yr.
Relationship to Owner___________________________________________________________________________________
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(Continued) 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 Pri-
xxxx Beneficiary on this form, I am waiving my right to receive benefits under the plan when my spouse
Beneficiary 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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Purchase Payments to the SAFECO Life Fixed Account Options will be allocated immediately upon receipt.
5. Investment Purchase Payments to the variable Portfolios may be invested in the SAFECO RST Money Market Portfolio
Instructions 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.
Choose one or more Initial Subsequent Investment Option
of the following. _______% _______% SAFECO RST Bond Portfolio
Whole percentages _______% _______% SAFECO RST Equity Portfolio
only. _______% _______% SAFECO RST Growth Opportunities Portfolio
_______% _______% SAFECO RST Money Market Portfolio
Total of all _______% _______% SAFECO RST Northwest Portfolio
percentages must _______% _______% SAFECO RST Small Company Value Portfolio
equal 100%. _______% _______% AIM V.I. Aggressive Growth Fund (Series I Shares)
_______% _______% AIM V.I. Growth Fund (Series I Shares)
_______% _______% American Century(r) VP Balanced
_______% _______% American Century(r)VP International
_______% _______% American Century(r)VP Value
_______% _______% Dreyfus IP - MidCap Stock Portfolio - Initial Shares
_______% _______% Dreyfus IP - Technology Growth Portfolio - Initial Shares
_______% _______% The Dreyfus Socially Responsible Growth Fund, Inc. - Initial Shares
_______% _______% Dreyfus VIF - Appreciation Portfolio - Initial Shares
_______% _______% Dreyfus VIF - Quality Bond Portfolio - Initial Shares
_______% _______% Federated High Income Bond Fund II
_______% _______% Federated Utility Fund II
_______% _______% Fidelity(r) VIP Growth Portfolio
_______% _______% Fidelity(r) VIP Growth & Income Portfolio
_______% _______% Fidelity(r) VIP Growth Opportunities Portfolio
_______% _______% Franklin Small Cap Fund - Class 2
_______% _______% Franklin U.S. Government Fund - Class 2
_______% _______% INVESCO VIF-Real Estate Opportunity Fund
_______% _______% JPMorgan U.S. Disciplined Equity Portfolio
_______% _______% Mutual Shares Securities Fund - Class 2
_______% _______% Xxxxxxx VS I Balanced Portfolio
_______% _______% Xxxxxxx VS I International Portfolio
_______% _______% Xxxxxxxxx Developing Markets Securities Fund - Class 2
_______% _______% Xxxxxxxxx Growth Securities Fund - Class 2
_______% N/A SAFECO Life DCA Fixed Account Option 6 months or 12 months
(Please allocate DCA percentages in Section 7)
_______% _______% SAFECO Life Enhanced Fixed Account Option
SAFECO Life Guaranteed Interest Period Fixed Account Option
_______% _______% 1-Year Guaranteed Period
_______% _______% 2-Year Guaranteed Period
_______% _______% 3-Year Guaranteed Period
_______% _______% 4-Year Guaranteed Period
_______% _______% ______-Year Guaranteed Period (as approved by SAFECO Life. Contact
your Registered Representative or SAFECO Life for the availability
of longer Guaranteed Periods.)
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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 Plans.)
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7. Transfers [] I have chosen to allocate some or all of my initial Purchase Payment to the Dollar Cost Averaging Fixed
Account Option and elect to have monthly transfers made to the Portfolios listed below.
[] 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) or _______% from the
[]_____________________________________ Portfolio or [] Enhanced Fixed Account Option []monthly
[]quarterly to the Portfolios listed below.
2. [] Appreciation or Interest Sweep ($10,000 minimum account balance required): I elect to have the
[] appreciation of the SAFECO RST Money Market Portfolio or [] the interest earned on the Enhanced
Fixed Account Option (up to 15% each Contract Year) transferred [] monthly [] quarterly
[]annually to the Portfolios listed below. Appreciation or Interest Sweep cannot be used to
transfer money to the Fixed Account Options or to the SAFECO RST Money Market Portfolio.
3. [] Portfolio Rebalancing ($10,000 minimum account balance required): I elect to rebalance my
Portfolios [] quarterly [] semiannually [] annually.
____% SAFECO RST Bond Portfolio ____% Dreyfus VIF - Quality Bond Portfolio -
____% SAFECO RST Equity Portfolio Initial Shares
____% SAFECO RST Growth Opportunities Portfolio ____% Federated High Income Bond Fund II
____% SAFECO RST Money Market Portfolio ____% Federated Utility Fund II
____% SAFECO RST Northwest Portfolio ____% Fidelity(r) VIP Growth Portfolio
____% SAFECO RST Small Company Value Portfolio ____% Fidelity(r) VIP Growth & Income Portfolio
____% AIM V.I. Aggressive Growth Fund (Series I ____% Fidelity(r) VIP Growth OpportunitiesPortfolio
Shares) ____% Franklin Small Cap Fund - Class 2
____% AIM V.I. Growth Fund (Series I Shares) ____% Franklin U.S. Government Fund - Class 2
____% American Century(r) VP Balanced ____% INVESCO VIF-Real Estate Opportunity Fund
____% American Century(r) VP International ____% JPMorgan U.S. Disciplined Equity Portfolio
____% American Century(r) VP Value ____% Mutual Shares Securities Fund - Class 2
____% Dreyfus IP - MidCap Stock Portfolio - ____% Xxxxxxx VS I Balanced Portfolio
Initial Shares ____% Xxxxxxx VS I International Portfolio
____% Dreyfus IP - Technology Growth Portfolio - ____% Xxxxxxxxx Developing Markets Securities
Initial Shares Fund - Class 2
____% The Dreyfus Socially Responsible Growth ____% Xxxxxxxxx Growth Securities Fund - Class 2
Fund, Inc.- Initial Shares
____% Dreyfus VIF - Appreciation Portfolio - Initial
Shares
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8. Telephone Transfer [] I hereby authorize SAFECO Life Insurance Company (SAFECO Life) to accept and act on telephone
Authorization 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 Life receives written revocation from me.
SAFECO Life will employ reasonable procedures to confirm that instructions communicated by telephone are
genuine. SAFECO Life reserves the right to refuse telephone instructions from any caller when unable to
confirm to SAFECO Life's satisfaction that the caller is authorized to give those instructions.
To transfer by telephone, call SAFECO Life at 1-800-4SAFECO (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.
FULL NAME OF AUTHORIZED THIRD PARTY:____________________________________________________________________
IDENTIFICATION INFORMATION: My mother's maiden name is:___________________________________
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9. Statement of Have you received a current Prospectus? [] Yes [] No
Owner(s)
Do you have any existing life insurance policies or annuity contracts with this or any other company?
[] Yes [] No
Will the annuity applied for here replace any annuity or life insurance from this or any other company?
[] Yes [] No If yes, give company name and policy number.
Company Name:_____________________________________________________ Policy Number:___________________
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 when contract values and annuity payments are based on
investment performance of the Separate Account, the dollar amounts cannot be
predicted or guaranteed. I also understand that withdrawals from the Guaranteed
Interest Period Fixed Account Option before the end of the Guaranteed Period
will be subject to a market value adjustment that will increase or decrease the
cash surrender benefit. With this in mind, I believe that the Contract is
consistent with my financial needs.
__________________________________________________________________ ________________________________
Signature of Owner Signed in City, State
__________________________________________________________________ __________________________________
Signature of Joint Owner (if applicable) Date
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10. 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 ERISA:
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.
___________________________________________________________________________ ____________________
Plan Administrator Signature Date
Contribution Frequency:
[] Annual (01) [] Bi-Weekly (26) Deductions will begin the month of:
[] Quarterly (04) [] Weekly (52) _______________________________________________
[] Monthly (12) [] 10 Pay Periods Month(s) to exclude:
[] Semi-Monthly (24) _______________________________________________
[] Other: ________________________________________ Contribution per pay frequency:
$__________________________________________
Source of Contribution: Anticipated annual contributions:
[] Employee Salary Reduction $________________________________________
[] Employer (Amount must be provided)
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11. Registered Does the applicant have any existing life insurance policies or annuity contracts with this or any other
Representative company? [] Yes [] No
Information
To the best of my knowledge, the annuity applied for here [] does [] does not replace any life
insurance or annuity in this or any other company.
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.
__________________________________________________________________ ____________________ _________
Registered Representative's Name (please print) Stat # %
__________________________________________________________________ ____________________ _________
Registered Representative's Name (please print) Stat # %
__________________________________________________________________ _________________________________
Agency State/Location ID #
__________________________________________________________________ ( )___________________
Registered Representative's Signature Telephone Number
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