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[LOGO] PACIFIC LIFE Pacific Life Insurance Company PACIFIC INNOVATIONS
X.X. Xxx 0000 - Xxxxxxxx, XX 00000-0000 VARIABLE ANNUITY APPLICATION
xxx.XxxxxxxXxxx.xxx - (000) 000-0000
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MAILING INSTRUCTIONS: Send this APPLICATIONS WITH PAYMENT (AND/OR ADDITIONAL APPLICATIONS WITHOUT PAYMENT:
completed application as follows: PAYMENTS):
REGULAR MAIL DELIVERY: Pacific Life Insurance REGULAR MAIL DELIVERY: Pacific Life
Company, Insurance Company,
IF YOU NEED ASSISTANCE IN COMPLETING X.X. Xxx 000000, Xxxxxxxx, XX 00000-0000 X.X. Xxx 0000, Xxxxxxxx, XX 00000-0000
THIS FORM, PLEASE CALL (000) 000-0000. EXPRESS MAIL DELIVERY: Pacific Life Insurance EXPRESS MAIL DELIVERY: Pacific Life
Company, Insurance Company,
C/O FCNPC, 0000 X. Xxxxxx Xxxxxxx, Xxx. 000, 1111 X. Xxxxxx Parkway, Ste. 205, Pasadena,
Xxxxxxxx, XX 00000 XX 00000
1. OWNER IF TRUST IS OWNER, ALSO COMPLETE TRUST AGREEMENT CERTIFICATION FORM. CHECK PRODUCT GUIDELINES FOR MAXIMUM ISSUE AGE.
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Name (FIRST, MIDDLE INITIAL, LAST) Birth Date (MO/DAY/YR) Sex
______________________________________________________________________ __ __/__ __/__ __ __ __ / / M / / F
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Xxxxxx Xxxxxxx Xxxx, Xxxxx, XXX Code SSN/TIN
___________________________________________ __________________________________________________________ _______________________
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ADDITIONAL OWNER NOT APPLICABLE FOR QUALIFIED CONTRACTS. CHECK ONE: / / JOINT / / CONTINGENT
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Name (FIRST, MIDDLE INITIAL, LAST) Birth Date (MO/DAY/YR) Sex
______________________________________________________________________ __ __/__ __/__ __ __ __ / / M / / F
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Xxxxxx Xxxxxxx Xxxx, Xxxxx, XXX Code SSN/TIN
___________________________________________ __________________________________________________________ _______________________
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2. ANNUITANT IF OWNER(S) AND ANNUITANT(S) ARE THE SAME, IT IS NOT NECESSARY TO COMPLETE THIS SECTION. CHECK PRODUCT GUIDELINES FOR
MAXIMUM ISSUE AGE.
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Name (FIRST, MIDDLE INITIAL, LAST) Birth Date (MO/DAY/YR) Sex
______________________________________________________________________ __ __/__ __/__ __ __ __ / / M / / F
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Street Address City, State, ZIP Code SSN
___________________________________________ __________________________________________________________ _______________________
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ADDITIONAL ANNUITANT COMPLETE THIS SECTION TO NAME ADDITIONAL ANNUITANT. NOT APPLICABLE FOR QUALIFIED CONTRACTS.
CHECK ONE: / / JOINT / / CONTINGENT
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Name (FIRST, MIDDLE INITIAL, LAST) Birth Date (MO/DAY/YR) Sex
______________________________________________________________________ __ __/__ __/__ __ __ __ / / M / / F
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Street Address City, State, ZIP Code SSN
___________________________________________ __________________________________________________________ _______________________
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3. BENEFICIARIES IF NO BOXES ARE CHECKED, DEFAULT WILL BE JOINT PRIMARY BENEFICIARIES. UNLESS OTHERWISE INDICATED, PROCEEDS WILL BE
DIVIDED EQUALLY. USE SPECIAL REQUESTS SECTION TO PROVIDE ADDITIONAL BENEFICIARIES OR BENEFICIARY INFORMATION.
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Name (FIRST, MIDDLE INITIAL, LAST) / / PRIMARY Relationship Percentage
/ / CONTINGENT %
_____________________________________________________________________________ _________________ _________________ ___________
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Name (FIRST, MIDDLE INITIAL, LAST) / / PRIMARY Relationship Percentage
/ / CONTINGENT %
_____________________________________________________________________________ _________________ _________________ ___________
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4. CONTRACT TYPE SELECT ONE. QUALIFIED CONTRACT PAYMENT TYPE
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/ / Non-Qualified / / SIMPLE XXX(1) / / Custodial XXX / / 457 IF NO YEAR IS INDICATED, CONTRIBUTION DEFAULTS TO
/ / Conduit XXX / / SEP-XXX / / 401(a) Pension(2) / / Xxxxx/HR10(2) CURRENT TAX YEAR.
/ / XXX / / Contributory / / 401(k)(2) / / TSA/403(b)(3)
Xxxx XXX / / Transfer......... $____________
/ / Conversion Xxxx XXX Conversion Date __ __/__ __/__ __ __ __ / / Rollover......... $____________
(1) COMPLETE XXXX/SIMPLE FORM. (2) COMPLETE QUALIFIED PLAN CERTIFICATION FORM.
(3) COMPLETE TSA CERTIFICATION FORM. / / Contribution..... $____________for tax year_____
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6. OPTIONAL DEATH BENEFIT
5. INITIAL PURCHASE PAYMENT SUBJECT TO STATE AVAILABILITY. ANNUITANT(S) MUST NOT
BE OVER 70 AT ISSUE. IF AN OPTION IS NOT SELECTED,
INDICATE THE FORM OF INITIAL PAYMENT. CHECK PAYABLE TO PACIFIC LIFE INSURANCE THE STANDARD DEATH BENEFIT IS THE DEFAULT.
COMPANY.
/ / STANDARD DEATH / / STEPPED-UP DEATH
/ / 1035 EXCHANGE/EST. TRANSFER $_________ / / AMT. ENCLOSED $_________ BENEFIT BENEFIT
/ / PREMIER DEATH BENEFIT
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7. REPLACEMENT WILL THE PURCHASE OF THIS ANNUITY RESULT IN THE REPLACEMENT, TERMINATION OR CHANGE IN VALUE OF ANY EXISTING LIFE
INSURANCE OR ANNUITY IN THIS OR ANY OTHER COMPANY? / / Yes / / No IF YES, PROVIDE THE INFORMATION BELOW AND ATTACH ANY REQUIRED
STATE REPLACEMENT AND/OR 1035 EXCHANGE/TRANSFER FORMS. USE THE SPECIAL REQUESTS SECTION FOR ADDITIONAL INSURANCE COMPANIES AND
CONTRACT NUMBERS.
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Insurance Company Name Contract Number Contract Type Being Replaced
/ / Life Insurance / / Fixed Annuity
/ / Variable Annuity
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8. TELEPHONE/ELECTRONIC AUTHORIZATION I WILL RECEIVE THIS PRIVILEGE AUTOMATICALLY. By checking "yes," I am authorizing and directing
Pacific Life to act on telephone or electronic instructions from any other person(s) who can furnish proper identification. Pacific
Life will use reasonable procedures to confirm that these instructions are authorized and genuine. As long as these procedures are
followed, Pacific Life and its affiliates and their directors, trustees, officers, employees, representatives and/or agents, will
be held harmless for any claim, liability, loss or cost. / / Yes
9. ELECTRONIC DELIVERY AUTHORIZATION By checking "yes," I authorize Pacific Life to provide my statements, prospectuses and other
information electronically. I understand that I must have internet access to use this service and there may be access fees charged
by the internet service provider. / / Yes
Email address:__________________________ @ _______________________ .___________
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10. SPECIAL REQUESTS IF ADDITIONAL SPACE IS NEEDED, ATTACH LETTER SIGNED AND DATED BY OWNER(S).
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11. ALLOCATION OPTIONS USE WHOLE PERCENTAGES ONLY. ALLOCATIONS MUST EQUAL 100%.
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MANAGER: PORTFOLIO: MANAGER: PORTFOLIO:
_____% AIM ..................BLUE CHIP _____% Janus ............................FOCUSED 30
_____ AIM ..................AGGRESSIVE GROWTH _____ Lazard ...........................MID-CAP VALUE
_____ Alliance Capital .....AGGRESSIVE EQUITY _____ Lazard ...........................INTERNATIONAL VALUE
_____ Alliance Capital .....EMERGING MARKETS _____ MFS ..............................CAPITAL OPPORTUNITIES
_____ Capital Guardian .....DIVERSIFIED RESEARCH _____ MFS ..............................MID-CAP GROWTH
_____ Capital Guardian .....SMALL-CAP EQUITY _____ MFS ..............................GLOBAL GROWTH
_____ Capital Guardian .....INTERNATIONAL LARGE-CAP _____ Mercury Asset Management .........EQUITY INDEX
_____ Xxxxxxx Xxxxx ........EQUITY _____ Mercury Asset Management .........SMALL-CAP INDEX
_____ Xxxxxxx Sachs ........I-NET TOLLKEEPER _____ Xxxxxx Xxxxxxx ...................REIT
_____ INVESCO ..............FINANCIAL SERVICES _____ PIMCO ............................GOVERNMENT SECURITIES
_____ INVESCO ..............HEALTH SCIENCES _____ PIMCO ............................MANAGED BOND
_____ INVESCO ..............TECHNOLOGY _____ Pacific Life .....................MONEY MARKET
_____ INVESCO ..............TELECOMMUNICATIONS _____ Pacific Life .....................HIGH YIELD BOND
_____ X.X. Xxxxxx ..........MULTI-STRATEGY _____ Salomon ..........................LARGE-CAP VALUE
_____ X.X. Xxxxxx ..........EQUITY INCOME _____ Pacific Life .....................FIXED
_____ Janus ................STRATEGIC VALUE
_____ Janus ................GROWTH LT _____ TOTAL MUST EQUAL 100%
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12. STATEMENT OF APPLICANT I received prospectuses for this variable annuity contract. After reviewing my financial background with
my agent, I believe this contract will meet my insurable needs and financial objectives. If applicable, I considered the
appropriateness of full or partial replacement of any existing life insurance or annuity. I understand that as a result of the
investment experience of the variable investment options, my contract value may increase or decrease and is not guaranteed. I
discussed the fees and charges for this contract with my agent, including withdrawal charges.
If there are joint applicants, the issued contract will be owned by the joint applicants as Joint Tenants With Right of Survivorship
and not as Tenants in Common.
My signature certifies that the taxpayer identification number is correct. The following sentence applies only if you are not
subject to withholding. I am not subject to backup withholding either because: 1) I am exempt; 2) I have not been notified that I
am subject to backup withholding resulting from failure to report all interest or dividends; 3) I have been notified that I am no
longer subject to backup withholding. The IRS does not require my consent to any provision of this document other than the
certifications required to avoid backup withholding.
THESE STATES REQUIRE INSURANCE COMPANIES TO PROVIDE A FRAUD WARNING STATEMENT.
PLEASE REFER TO THE FRAUD WARNING STATEMENT FOR YOUR STATE AS INDICATED BELOW.
PLEASE CHECK FOR STATE PRODUCT AVAILABILITY.
COLORADO It is unlawful to knowingly provide false, incomplete, misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil
damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or
information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with
regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the
Department of Regulatory Services.
NEW JERSEY Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
VIRGINIA It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
WASHINGTON Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement
in an application for insurance may be guilty of a criminal offense under law.
ALL OTHER STATES: 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 may be a crime and may subject such person to
criminal and civil penalties.
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Signed at: City State Solicited at: State SIGN Owner's Signature Date
HERE
__________________________________ ____________ ____________________ ___________________________ __ __/__ __/__ __ __ __
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SIGN Joint Owner's Signature Date
HERE IF APPLICABLE
___________________________ __ __/__ __/__ __ __ __
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13. AGENT'S STATEMENT Do you have reason to believe that any existing life insurance or annuity has been (or will be) surrendered,
withdrawn from, loaned against, changed or otherwise reduced in value, or replaced in connection with this transaction assuming the
contract applied for will be issued? / / YES / / NO (MUST CHECK ONE) IF YES, EXPLAIN IN REPLACEMENT SECTION. I have explained to
the applicant how the annuity will meet their insurable needs and financial objectives.
I have discussed the appropriateness of replacement, and followed Pacific Life's written replacement guidelines.
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SIGN HERE Soliciting Agent's Signature Print Agent's Full Name Agent's ID Number
__________________________________________ __________________________________________ _____________________________________________
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Agent's Phone Number Agent's E-Mail Address Option
__________________________________________ __________________________________________ / / A / / B / / C
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Broker/Dealer's Name Brokerage Account Number OPTIONAL.
__________________________________________ __________________________________________
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