EXHIBIT 5
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Contract #_____________________
(For H.O. Use Only)
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C.M. LIFE INSURANCE COMPANY
000 Xxxxxx Xxxxxx
Xxxxxxxx, XX 00000
VARIABLE ANNUITY CONTRACT APPLICATION
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1. CONTRACT OWNER INFORMATION NOTE: Contract Owner must be same as Annuitant for all types of IRAs and 403(b) plans.
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Name (First, MI, Last) Tax I.D./Social Security #
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Address (No., Street) Birth Date (Mo/Day/Yr)
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Address (City, State, Zip) Sex: [_] Male [_] Female Telephone Number
( )
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2. JOINT CONTRACT OWNER INFORMATION NOTE: . Joint ownership only allowed between spouses.
. Unless otherwise specified, both signatures will be
required for all Contract Owner transactions.
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Name (First, MI, Last) Social Security #
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Address (No., Street) Birth Date (Mo/Day/Yr)
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Address (City, State, Zip) Sex: [_] Male [_] Female Telephone Number
( )
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3. ANNUITANT INFORMATION NOTE: . Add Annuitant information only if different from Contract
Owner.
. For additional instructions use Item 11.
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Name (First, MI, Last) Tax I.D./Social Security #
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Address (No., Street) Birth Date (Mo/Day/Yr)
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Address (City, State, Zip) Sex: [_] Male [_] Female Telephone Number
( )
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4. BENEFICIARY INFORMATION NOTE: . In the event of the death of a Joint Contract Owner, the
surviving spouse shall become the Primary Beneficiary.
. For additional instructions use Item 11.
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Primary Beneficiary: Name (First, MI, Last) Relationship to Contract Tax I.D./Social Security #
Owner
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Address (No., Street) Birth Date (Mo/Day/Yr) Telephone Number
( )
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Address (City, State, Zip)
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Contingent Beneficiary: Name (First, MI, Last) Relationship to Contract Owner Tax I.D./Social Security #
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Address (No., Street) Birth Date (Mo/Day/Yr) Telephone Number
( )
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Address (City, State, Zip)
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5. PLAN INFORMATION
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Non-Qualified Plan: [_] Individual Plan
Qualified Plan: [_] Regular XXX - Tax year(s) _____._____
[_] XXX Rollover/Transfer
[_] SEP-XXX
[_] Xxxx XXX
[_] 457 Deferred Compensation Plan
[_] TSA Plan (check one): Regular___Transfer___
[_] Corporate, Plan Type Plan _____________________________________________________
[_] Other _________________________________________________________________________
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6. INITIAL PURCHASE PAYMENT $_____________
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MUVA94a
[Product Name]
88
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7. HEALTH INFORMATION
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Do you have any reason to believe that the Death Benefit will become payable to the Beneficiary in the first
Contract Year? Yes [_] No [_]
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8. ANNUITY ACTIVITY
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. Have you purchased another Connecticut Mutual Life or C.M. Life Annuity in the past 12 months? Yes [_] No [_]
. Will the annuity applied for replace or change any existing individual or group life insurance or annuity? Yes [_] No [_]
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NOTE: . The Annuity Date must be the first day of a calendar month.
9. ANNUITY DATE __________________ . The Annuity Date cannot be later than the earlier of the Annuitant's 100th
(Mo/Day/Yr) birthday or the maximum date permitted under state law.
. If no election is made, the Annuity Date will be the earlier of the Annuitant's
100th birthday or the maximum date permitted under state law.
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10. ANNUITY OPTIONS NOTE: If no election is made 30 days before the Annuity Date, payments will be made under Option B
with a 10 Year Period Certain.
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[_] Option A - Life Income
[_] Option B - Life Income with Period Certain: [_] 5 Yr. [_] 10 Yr. [_] 20 Yr.
[_] Option C - Joint and Last Survivor
[_] Option D - Joint and 2/3 Survivor
[_] Option E - Period Certain: # of Years ______
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11. MISCELLANEOUS INSTRUCTIONS/COMMENTS
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12. CONTRACT OWNER AND ANNUITANT SIGNATURES
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I hereby represent that the above information is correct and true to the best of my knowledge and belief and agree that this
application shall be a part of the Contract issued by the Company. Any person who, with the intent to defraud or knowing that he
is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is
guilty of insurance fraud. ALL PAYMENTS AND VALUES PROVIDED BY THE CONTRACT BEING APPLIED FOR WHEN BASED ON INVESTMENT EXPERIENCE
OF A VARIABLE ACCOUNT ARE VARIABLE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. I acknowledge receipt of a current prospectus for the
Contract.
Signed at: ___________________________ ___________ On: _____/_____/_____
City State (Mo/Day/Yr)
Contract Owner Signature____________________________________________________________________________________________________________
Joint Contract Owner Signature _____________________________________________________________________________________________________
Annuitant Signature (If other than a Contract Owner)________________________________________________________________________________
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13. NASD REGISTERED REPRESENTATIVE/AGENT/BROKER INFORMATION
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Will the annuity applied for replace or change any existing individual or group life insurance or annuity? If yes, I have complied
with all state replacement requirements. [_] Yes [_] No
Is this replacement meant to be a tax-free exchange under Section 1035? [_] Yes [_] No
I certify that I am NASD registered and state licensed for variable annuity contracts where this application is written and
delivered.
Signature of NASD Registered Representative/Agent/Broker________________________________Phone Number ( ) __________________________
Print Name and License #/ Code_____________________________________________________________________________________________________
Name and Address of Firm __________________________________________________________________________________________________________
City _____________________________________________ State ___________________________________ Zip___________________________________
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Make check(s) payable to C.M. Life and mail this signed Application and the check to: C.M. Life Insurance Company
Annuity Service Center, H565
P. O. Xxx 0000
Xxxxxxxxxxx, XX 00000-0000
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MUVA94a
89
