Deferred Variable Annuity Application Sample Contracts

5a. NON-QUALIFIED CONTRACT 5b. QUALIFIED CONTRACT Indicate type and amount of initial Payment below. Indicate type of plan for new contract, source of funds, and amount OR below.

Deferred Variable Annuity Application • April 27th, 2011 • Variable Separate Account

• Contract Type
  Deferred Variable Annuity Application
• Filed
  April 27th, 2011
• Company
  Variable Separate Account