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APPLICATION FOR CONSULTANT I AND II VARIABLE ANNUITY
LINCOLN BENEFIT LIFE COMPANY, X.X. XXX 00000, XXXXXXX, XX 00000-0000
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IMPORTANT NOTICE: Any person who, with 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.
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ANNUITANT: Name______________________________________________ Birth Date _____-_____-_____ Age _____________________
Soc. Sec. No. ______-_____-______ Telephone Number (_______) _______-____________________ Sex _______Male _______Female
Street Address______________________________________________ City _______________ State__________ ZIP ________ - _____
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OWNER (IF OTHER): Name__________________________________________________________________ Soc. Sec. No. _______-______-______
Street Address______________________________________________ City _______________ State__________ ZIP ________-_______
Birth Date ______-______-______ Relationship to Annuitant______________________________________________________________________
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PRIMARY BENEFICIARY: Name ____________________________________________________________ Soc. Sec. No. ______-_______-______
Street Address______________________________________________ City ______________ State _________ ZIP ________-_______
Relationship to Owner ____________________________________________________________________ Soc. Sec. No. ______-______-_______
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CONTINGENT BENEFICIARY: Name ____________________________________________________________ Soc. Sec. No. _______-______-______
Street Address______________________________________________ City ______________ State _________ ZIP ________-_______
Relationship to Owner ____________________________________________________________________ Soc. Sec. No. _______-______-______
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PURCHASE PAYMENT INFORMATION: First Purchase Payment of $ ______________________ submitted herewith (Check or Money Order should
be payable to Lincoln Benefit Life Company). A copy of this application duly signed by the agent will constitute receipt for such
amount. If this application is declined, there will be no liability on the part of the Company, and any sums submitted with this
application will be refunded. The Contract Owner intends to make subsequent purchase payments of $_________________ on a
/ / monthly(XXX) / / quarterly / / semi-annually / / annual basis / / single payment.
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PURCHASE PAYMENT ALLOCATION: (WHOLE PERCENTAGES ONLY AND MUST EQUAL 100%)
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MFS VARIABLE INSURANCE TRUST FIDELITY VIPF FIDELITY VIPF II
________% Growth with Income ________% Money Market ________% Asset Manager
________% Research ________% Equity Income ________% Contrafund
________% Emerging Growth ________% Overseas ________% Index 500
________% Total Return ________% Growth XXXXXXX VARIABLE LIFE INVESTMENT FUND
________% New Discovery XXXXX AMERICAN FUND ________% Bond
JANUS ASPEN SERIES ________% Income & Growth ________% Balanced
________% Flexible Income ________% Small Capitalization ________% Growth and Income
________% Balanced ________% Growth ________% Global Discovery
________% Growth ________% MidCap Growth ________% International
________% Aggressive Growth ________% Leveraged AllCap FEDERATED INSURANCE MANAGEMENT SERIES
________% Worldwide Growth X. XXXX PRICE EQUITY SERIES ________% Utility Fund II
STRONG VARIABLE INSURANCE FUNDS, INC. ________% New America Growth ________% Fund for U.S. Gov't Securities
________% Discovery Fund II ________% MidCap Growth ________% High Income Bond Fund II
________% Opportunity Fund II ________% Equity Income GUARANTEED MATURITY FIXED ACCOUNT
________% Growth Fund II FIXED ACCOUNT ________% 1 year in Guarantee Period
X. XXXX PRICE INTERNATIONAL SERIES, INC. ________% ________% 3 year in Guarantee Period
________% International Stock ________% 5 year in Guarantee Period
________% 7 year in Guarantee Period
________% 10 year in Guarantee Period
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VAA 9830 Page 1
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Plan Name/ Form Number:______________________________________ (If not designated, app will be processed for Consultant I.)
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XXX (PRE-AUTHORIZED METHOD) I authorize the Company to collect $_____________________, on the due date specified, by initiating
electronic debit entries to my account. A balance must exist before the program can commence. ATTACH VOIDED CHECK. (Credit
unions and savings accounts are not eligible.)
Signature of Authorized Account Owner ____________________________________________________ Date ______________________________
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Will this annuity replace or change any existing policy? __Yes ___ No If Yes, give name of company, policy issue date,
policy number and cost basis._____________________________________________________________________________________________________
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TAX QUALIFIED?
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/ / XXX / / SEP-XXX / / Other__________________________
/ / 401 (a) / / {LBL Prototype / / Funding Vehicle}
/ / 401 (k) / / {LBL Prototype / / Funding Vehicle}
/ / 403 (b) / / Simple XXX / / Xxxx XXX
Tax year for which contribution is to be applied______________________________________
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I declare: To the best of my knowledge and belief, all statements and answers are true, complete and correctly reported. Lincoln
Benefit Life may correct or endorse this application. No change shall be made in the annuity amount or plan or issue age by such
endorsement or correction. Under penalties of perjury, I certify that the Social Security Number stated herein is my correct
taxpayer ID number, and I am not subject to backup withholding. I UNDERSTAND THAT ANNUITY PAYMENTS AND SURRENDER VALUES PROVIDED
UNDER THE SEPARATE ACCOUNT ARE VARIABLE AND ARE NOT GUARANTEED AS TO A FIXED DOLLAR AMOUNT. RECEIPT OF A CURRENT VARIABLE ANNUITY
PROSPECTUS IS HEREBY ACKNOWLEDGED.
/ / Please send me a copy of the Statement of Additional Information to the Prospectus.
Signed at ________________________________________________________________ On (date) _____________-____________-_____________
City/State Month Day Year
Owner's Signature ________________________________________________________________________________________________________________
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TO THE AGENT: To the best of your knowledge will this annuity replace or change any existing life insurance or annuity in this
or any other company? / / Yes / / No
Agent Name ___________________________________________________ Agent's Signature _______________________________________________
Agent Number _________________________________________________ Agent's Phone No. _______________________________________________
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TO THE REGISTERED REPRESENTATIVE/BROKER-DEALER: CHOOSE OPTION:
/ / OPTION A / / OPTION B / / OPTION C
Broker/Dealer _____________________________________________ Telephone _______________________________________________________
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VAA 9830 Page 2
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TRANSFER AUTHORIZATION:
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/ / I authorize Lincoln Benefit Life Company ("LBL") to act upon the written or telephone instructions from the person named
below to 1) change the allocation of payments and deductions between and among the subaccounts; and 2) transfer amounts among
the subaccounts. Neither LBL nor any person authorized by us will be responsible for any claim, loss, liability, or expense
in connection with such transfer authorization if LBL, or its employees, acts upon transfer instructions in good faith. LBL
may establish procedures to determine the proper identification of the person requesting the transfer.
Name and Relationship of Authorized Person:
Name________________________________________________ Relationship_____________________________ SS#___________________________
Signature of Owner_______________________________________________________________ Date_________________________________________
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DOLLAR COST AVERAGING/PORTFOLIO REBALANCING:
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MFS VARIABLE INSURANCE TRUST FIDELITY VIPF FIDELITY VIPF II
DCA PR DCA PR DCA PR
$____ ____% Growth with Income $____ ____% Money Market $____ ____% Asset Manager
$____ ____% Research $____ ____% Equity Income $____ ____% ContraFund
$____ ____% Emerging Growth $____ ____% Overseas $____ ____% Index 500
$____ ____% Total Return $____ ____% Growth
$____ ____% New Discovery
JANUS ASPEN SERIES XXXXX AMERICAN FUND XXXXXXX VARIABLE LIFE INVESTMENT FUND
DCA PR DCA PR DCA PR
$____ ____% Flexible Income $____ ____% Income & Growth $____ ____% Bond
$____ ____% Balanced $____ ____% Small Capitalization $____ ____% Balanced
$____ ____% Growth $____ ____% Growth $____ ____% Growth and Income
$____ ____% Aggressive Growth $____ ____% MidCap Growth $____ ____% Global Discovery
$____ ____% Worldwide Growth $____ ____% Leveraged AllCap $____ ____% International
STRONG VARIABLE INSURANCE FUNDS, INC. X. XXXX PRICE EQUITY SERIES FEDERATED INSURANCE MANAGEMENT SERIES
DCA PR DCA PR DCA PR
$____ ____% Discovery Fund II $____ ____% New America Growth $____ ____% Utility Fund II
$____ ____% Opportunity Fund II $____ ____% MidCap Growth $____ ____% Fund for U.S. Gov't Securities II
$____ ____% Growth Fund II $____ ____% Equity Income $____ ____% High Income Bond Fund II
X. XXXX PRICE INTERNATIONAL SERIES, INC. FIXED ACCOUNT GUARANTEED MATURITY FIXED ACCOUNT
DCA PR DCA PR DCA PR
$____ ____% International Stock $____ ____% (Restrictions apply $____ ____% 1 Year Guarantee Period
for DCA--see prospectus for details) $____ ____% 3 Year Guarantee Period
$____ ____% 5 Year Guarantee Period
$____ ____% 7 Year Guarantee Period
$____ ____% 10 Year Guarantee Period
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VAA 9830 Page 3
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SYSTEMATIC WITHDRAWALS: ($50.00 Minimum Withdrawal)
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I authorize systematic withdrawals of :
/ / $___________________ / / Interest Earnings / / % Percentage of Purchase Payments
from my contract value to commence during the month of ________________________. Withdrawals may be subject to penalties and/or
a Deferred Sales Charge. Additional restrictions may apply to contracts held as a Qualified Plan.
Frequency: ____ Monthly _____Quarterly _____Semi-Annual _____Annual
Please indicate the amount or percentage of the withdrawal from the chosen Subaccount(s)
/ / Dollar Amount Specified
/ / Percentage Specified
/ / Or xxxx this box if the withdrawal is to be taken from the account value on a Pro Rata basis.
MFS VARIABLE INSURANCE TRUST FIDELITY VIPF FIDELITY VIPF II
_________ Growth with Income _________ Money Market _________ Asset Manager
_________ Research _________ Equity Income _________ ContraFund
_________ Emerging Growth _________ Overseas _________ Index 500
_________ Total Return _________ Growth
_________ New Discovery
JANUS ASPEN SERIES XXXXX AMERICAN FUND XXXXXXX VARIABLE LIFE INVESTMENT FUND
_________ Flexible Income _________ Income & Growth _________ Bond
_________ Balanced _________ Small Capitalization _________ Balanced
_________ Growth _________ Growth _________ Growth and Income
_________ Aggressive Growth _________ MidCap Growth _________ Global Discovery
_________ Worldwide Growth _________ Leveraged AllCap _________ International
STRONG VARIABLE INSURANCE FUNDS, INC. X. XXXX PRICE EQUITY SERIES FEDERATED INSURANCE MANAGEMENT SERIES
_________ Discovery Fund II _________ New America Growth _________ Utility Fund II
_________ Opportunity Fund II _________ MidCap Growth _________ Fund for U.S. Gov't Securities II
_________ Growth Fund II _________ Equity Income _________ High Income Bond Fund II
X. XXXX PRICE INTERNATIONAL SERIES, INC. FIXED ACCOUNT GUARANTEED MATURITY FIXED ACCOUNT
_________ International Stock _________ ________ 1 Year Guarantee Period
________ 3 Year Guarantee Period
________ 5 Year Guarantee Period
________ 7 Year Guarantee Period
________ 10 Year Guarantee Period
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VAA 9830 Page 4
