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Exhibit (b)(5)(i)
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Group/Owner application for Flexible Purchase Payment Deferred Combination Fixed and Variable Annuity Contract ("Contract
Application") NORTH AMERICAN SECURITY LIFE INSURANCE COMPANY, P.O. 818, BOSTON, MA 02116
Payment (or original of exchange/transfer request) must accompany
Application: Please make check payable to NORTH AMERICAN SECURITY LIFE (the
"Company") and send to above address.
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1. GROUP/OWNER
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2. ADDRESS 3. TAX ID #:
Street
City State Zip
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4. TRUSTEE(S)(if applicable)
Ownership: Trustee(s) specified in question 4 will be the owner(s) of the contract.
5. Unless the following box is check, confirmation statements for the plan will be mailed to the address above.
Mail statements directly to the Participant.
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6. PLAN SELECTION - TYPE OF PLAN
/ / Non-Qualified
/ / Qualified (Indicate type below)
/ / Profit Sharing / / 403(b) / / IRA Tax Year ________
/ / Money Purchase / / 401(k) / / SEP IRA Tax Year ________
/ / Defined Benefit / / IRA Rollover / / 457
/ / Xxxxx (HR-10) / / IRA Transfer / / Other __________________________
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7. INVESTMENT OPTIONS:
Conservative Asset Allocation Investment Quality Bond Global Equity Pasadena Growth
Moderate Asset Allocation U.S. Government Securities Growth & Income Global Government Bond
Aggressive Asset Allocation Money Market Strategic Income Equity
Growth
FIXED ACCOUNT OPTIONS: 1 Year Fixed Account 3 Year Fixed Account 6 Year Fixed Account
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8. SPECIAL INSTRUCTIONS
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I hereby represent the answers to the above questions to be correct and
true to the best of my knowledge and belief and agree that this application
shall be a part of any Contract issued by the Company. ALL PAYMENTS AND
VALUES PROVIDED BY THIS CONTRACT WHEN BASED ON THE INVESTMENT EXPERIENCE OF
THE VARIABLE ACCOUNT ARE VARIABLE AND NOT GUARANTEED AS TO DOLLAR AMOUNT.
ALL PAYMENTS AND VALUES BASED ON THE FIXED ACCOUNT ARE SUBJECT TO A MARKET
VALUE ADJUSTMENT FORMULA, THE OPERATION OF WHICH MAY RESULT IN UPWARD AND
DOWNWARD ADJUSTMENTS IN AMOUNTS PAYABLE. I acknowledge receipt of an
effective Prospectus describing the Contract applied for.
Signed at
Date -------------------------------------------------------- -----------------------------------------------
City State
Authorized Signature
for Group/Owner Agent
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Print Agent Name and Phone Number
Trustee(s) Agent
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Signature(s) Signature of Agent
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AGENT: Will this Contract replace or change any existing life insurance or annuity in this or any other company?
/ / Yes / / No If yes, please explain under Special Instructions.
General Agent
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Branch Office Address (Tel)
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VFA-CON-APP