Exhibit b (5)
APPLICATION
FOR AN INDIVIDUAL DEFERRED ANNUITY CONTRACT
In this application Valley Forge Life Insurance Company is referred to as "we",
"our" or "us".
1. Desired Contract:_________________________________________________
2. Proposed Annuitant:
Name:______________________________________________________________ Social Security #:_______________________________
(Last) (First) (Initial)
Address:_____________________________________________________________________________________________________________________
(Street) (City) (State) (Zip)
Sex: |_| Male |_| Female Date of Birth:
(Month) (Day) (Year)
3. Proposed Owner (if other than proposed annuitant):
Name:______________________________________________________________________________________________________________________
_____________________________________________________Tax I.D. or Social Security #:___________________________________
Address:_____________________________________________________________________________________________________________________
(Street) (City) (State) (Zip)
4. Proposed Contingent Owner
Name: ____________________________________________________Tax I.D. or Social Security #:___________________________________
Address:_____________________________________________________________________________________________________________________
(Street) (City) (State) (Zip)
5. Beneficiary (include name and relationship to proposed annuitant):___________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
6. Desired Annuity Date:________________________________________________________________________________________________________
(Month) (Day) (Year)
7. Xxxxxxx Xxxxxxx Option. (If no box is checked, the contract will be issued with the Life Annuity with 10 Year Certain Period
as the annuity option.)
|_| Life Annuity
|_| Life Annuity with 10 Year Certain Period
|_| Life Annuity with 20 Year Certain Period
|_| Joint Life and Survivorship Annuity
|_| Joint Life Annuity with Payments Reduced One-Half at Payee's Death
|_| Other______________________________________________________________
If a joint life annuity is elected, complete the following for the joint
payee:
Name:_________________________________________________________________ Social Security #:_______________________________
(Last) (First) (Initial)
Sex: |_| Male |_| Female Date of Birth:_____________________________________________________
(Month) (Day) (Year)
8. The annuity will be used in the type of plan checked below:
|_|Corporate Qualified Pension Plan |_|Rollover Individual Retirement Annuity
|_|HR-10 |_|Tax Sheltered Annuity
|_|Simplified Employee Pension Plan |_|Contract will not be used in tax-qualified plan
|_|Regular Individual Retirement Annuity |_|Other:__________________________________________
|_|Spousal Individual Retirement Annuity
V206-356-A (also complete other side)
9. Contribution Submitted with Application: $_________________________
10. Will the contract applied for replace or change any life insurance or annuity coverage in force on the life of the proposed
annuitant? |_| Yes |_|
No
11. Corrections, notations, and changes made by us.____________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
The proposed annuitant will be the owner of the contract unless a different
owner is named in item 3 above. The proposed annuitant declares that all
statements and answers above are made a part of this application and that they
are complete and true, to the best of his or her knowledge and belief, and
correctly recorded. If we accept this application, the entire contract will
consist of this application, the contract to which it is attached and riders
attached to the contract. If the owner accepts the contract it means he or she
agrees to corrections, notations and changes made in item 11 above, except in
those states where written consent is required.
Dated at___________________________________________________ Signed______________________________________________________
Proposed Annuitant
This_______________Day of______________________ , 19_______ Signed______________________________________________________
Applicant (if other than proposed annuitant)
Witness____________________________________________________ By__________________________________________________________
Agent Signed and title of person signing for
corporation, partnership or trust as
applicant
V206-356-A
AGENT'S REPLACEMENT QUESTION
Do you have knowledge or reason to believe that the annuity applied for by this
application will replace or change any insurance or annuity coverage currently
in force on the life of the proposed annuitant? |_| Yes |_| No
Dated___________________________________________________________ Signed_________________________________________________________
Agent
AGENT TRANSMITTAL
NOTE: THE WRITING AGENT'S NAME MUST BE PRINTED. THE NAME ENTERED MUST BE IDENTICAL TO THE SA NAME ON
THE AGENT'S STATE LICENSE.
Agent Name______________________________________________________ Agent Code _______________________ Percent_____________________
Agent Name______________________________________________________ Agent Code _______________________ Percent_____________________
VFL MAST
SUPPLEMENT TO APPLICATION
(To Be Signed By the Applicant and Returned With the Application)
1. ALLOCATIONS: On issued contracts, your initial Net Purchase Payment
will be allocated as indicated below. Selections must total 100%. Minimum
initial allocation to any single subaccount is 1%. No fractional percentages.
These percentages will apply in future years but may be changed at any time
by the owner. (If no allocation is indicated, Prime Money Fund will be
automatically selected.)
Federated Advisers MFS Asset Management, Inc.
___% Corporate Bond Fund ___% Emerging Growth Series
___% Prime Money Fund ___% Growth with Income Series
___% Utility Fund ___% Limited Maturity Series
___% Research Series
___% Total Return Series
Fidelity Management and Research Company
___% Asset Manager Portfolio SoGen
___% Contrafund Portfolio ___% Overseas Portfolio
___% Equity-Income Portfolio
___% Index 500 Portfolio Xxx Xxx Associates Corporation
___% Emerging Markets Fund
Xxxx Xxxxx Management, Inc. ___% Gold and Natural Resources Fund
___% Growth Portfolio
___% MidCap Growth Portfolio Guaranteed Interest Option
___% Small Capitalization Portfolio ___% 1 Year ___% 7 Year
___% 3 Year ___% 10 Year
___% 5 Year
2. SUITABILITY:
A. Do you understand that the death benefit and surrender value may
increase or decrease depending on the investment experience of the
variable account? Yes___ No___
B. Do you believe that this policy will meet your insurance needs
and financial objectives? Yes ___ No ___
C. Have you received a current copy of the prospectus? Yes ___ No ___
Date___________________ Signed______________________________
Mo/Day/Year
