EXHIBIT 99.5
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SPINNAKER-Registered Trademark- ADVISOR VARIABLE ANNUITY SAFECO Life Insurance Company
[SAFECO Logo] INDIVIDUAL DEFERRED VARIABLE ANNUITY APPLICATION 0000 000xx Xxxxx XX
Xxxxxxx, XX 00000-0000
Telephone 0-000-000-0000
TTY/TDD 0-000-000-0000
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MINIMUM PURCHASE PAYMENT AMOUNTS
Initial Purchase Payment: $10,000
Minimum Allocations to the Fixed Account Options:
Dollar Cost Averaging (DCA) Fixed Account Option: $5,000
Guaranteed Interest Period Fixed Account Option: $1,000 for each selected Guaranteed Period
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1. OWNER
INFORMATION Name_____________________________________________________________________________________________________
First Middle Last
Mailing Address__________________________________________________________________________________________
Street City State Zip Code
Telephone (_____)________________________ Soc. Sec. #_____________________ Date of Birth_________________
JOINT OWNER Mo. Day Yr.
(NON-QUALIFIED ONLY)
Name_____________________________________________________________________________________________________
First Middle Last
Mailing Address__________________________________________________________________________________________
Street City State Zip Code
Telephone (_____)________________________ Soc. Sec. #_____________________ Date of Birth_________________
Mo. Day Yr.
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2. ANNUITANT
INFORMATION Name__________________________________________________________________________ / / Male / / Female
First Middle Last
(NON-QUALIFIED ONLY)
Mailing Address__________________________________________________________________________________________
Street City State Zip Code
Telephone (_____)________________________ Soc. Sec. #_____________________ Date of Birth_________________
Mo. Day Yr.
IF NO ANNUITANT IS SPECIFIED, THE OWNER WILL BE THE ANNUITANT.
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3. TYPE OF ANNUITY / / TSA / / DEFERRAL TSA / / TRANSFER FROM ANOTHER TSA
/ / Transfer TSA was an Annuity under IRC 403(b)
/ / IRA / / INDIVIDUAL RETIREMENT ANNUITY (IRA)
/ / Contribution for calendar year _________ to a / / Regular IRA or / / Xxxx XXX
/ / Rollover* from a / / Regular IRA or / / Xxxx XXX
/ / Transfer* from a / / Regular IRA or / / Xxxx XXX
The taxable year for which I first made a Xxxx XXX contribution was ________.
/ / Convert my Regular IRA by rollover or transfer to a Xxxx XXX.
/ / Rollover* from a Qualified Retirement Plan or TSA
SIMPLIFIED EMPLOYEE PENSION (SEP) IRA PLAN
/ / Salary Reduction (SARSEP). Only available if plan established prior to 1997.
SAVINGS INCENTIVE MATCH PLAN FOR EMPLOYEES (SIMPLE) IRA
/ / Rollover* from a SIMPLE IRA Original date of SIMPLE IRA ___/___/_____
/ / NON-QUALIFIED ANNUITY / / 1035 Exchange.*
* MUST COMPLETE FORM LP-1185, ROLLOVER, TRANSFER, AND/OR EXCHANGE REQUEST.
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4. TRANSFER & ROLLOVER, TRANSFER, AND EXCHANGES
REPLACEMENT Will the annuity applied for here replace any annuity or life insurance from this or any other company?
ANNUITY
/ / Yes / / No If yes, give policy number and full company name: Policy #:____________________
Company Name:____________________________________________________________________________________________
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-Registered Trademark- Registered trademark of SAFECO Corporation
-Registered Trademark- Spinnaker is a registered trademark of SAFECO Life Insurance Company
LPC-1161 3/00
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5. BENEFICIARY
PRIMARY: Name ______________________________________________________________ Percentage____________%
(PLEASE ATTACH A First Middle Last
SIGNED AND DATED Mailing Address________________________________________________________________________________________
LISTING OF ANY Street City State Zip Code
ADDITIONAL NAMES.) Soc. Sec. #______________________________ Date of Birth______________________ / / Male / / Female
Mo. Day Yr.
Relationship to Owner__________________________________________________________________________________
CONSENT OF SPOUSE REQUIRED FOR ERISA PLAN PARTICIPANT NAMING A NON-SPOUSE PRIMARY BENEFICIARY: I
consent to the above designation of Beneficiary. I understand that if anyone other than me is
designated as Primary Beneficiary on this form, I am waiving my right to receive benefits under the
plan when my spouse dies.
Signature of Spouse_____________________________________________________________ Date _______________
Mo. Day Yr.
/ / I am not married.
/ / PRIMARY
/ / CONTINGENT: Name_________________________________________________________ Percentage___________%
First Middle Last
Mailing Address________________________________________________________________________________________
Street City State Zip Code
Soc. Sec. #______________________________ Date of Birth_______________________ / / Male / / Female
Mo. Day Yr.
Relationship to Owner__________________________________________________________________________________
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6. INVESTMENT INITIAL SUBSEQUENT INVESTMENT OPTION
INSTRUCTIONS ------- ---------- -----------------
_______% _______% SAFECO RST Bond
_______% _______% SAFECO RST Equity
Choose one or more of _______% _______% SAFECO RST Growth Opportunities
the following. Whole _______% _______% SAFECO RST Money Market
percentages only. _______% _______% SAFECO RST Northwest
_______% _______% SAFECO RST Small Company Value
TOTAL OF ALL _______% _______% AIM V.I. Aggressive Growth
PERCENTAGES MUST _______% _______% AIM V.I. Growth
EQUAL 100%. _______% _______% American Century VP Balanced
_______% _______% American Century VP International
_______% _______% Dreyfus IP MidCap Stock
_______% _______% Dreyfus IP Technology Growth
_______% _______% The Dreyfus Socially Responsible Growth Fund, Inc.
_______% _______% Dreyfus VIF Appreciation
_______% _______% Dreyfus VIF Quality Bond
_______% _______% Federated High Income Bond Fund II
_______% _______% Federated Utility Fund II
_______% _______% Fidelity VIP Growth
_______% _______% Fidelity VIP III Growth & Income
_______% _______% Fidelity VIP III Growth Opportunities
_______% _______% Franklin Small Cap Fund - Class 2
_______% _______% Xxxxxxxx U.S. Government Fund - Class 2
_______% _______% INVESCO VIF-Real Estate Opportunity Fund
_______% _______% X.X. Xxxxxx U.S. Disciplined Equity
_______% _______% Xxxxxxx VLIF Balanced
_______% _______% Xxxxxxx VLIF International
_______% _______% Xxxxxxxxx Developing Markets Securities Fund - Class 2
_______% N/A SAFECO DCA Fixed Account Option / / 6 months OR / / 12 months
(PLEASE ALLOCATE DCA PERCENTAGES IN SECTION 8)
SAFECO Guaranteed Interest Period Fixed Account Option
_______% _______% 1-Year Guaranteed Period
_______% _______% 2-Year Guaranteed Period
_______% _______% 3-Year Guaranteed Period
_______% _______% 4-Year Guaranteed Period
_______% _______% ______-Year Guaranteed Period (AS APPROVED BY SAFECO LIFE.
CONTACT YOUR REGISTERED REPRESENTATIVE OR SAFECO LIFE FOR THE
AVAILABILITY OF LONGER GUARANTEED PERIODS.)
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(CONTINUED) Purchase Payments to the SAFECO Fixed Account Options will be allocated immediately upon receipt.
Purchase Payments to the variable Portfolios may be invested in the SAFECO RST Money Market Portfolio
INVESTMENT until the expiration of 15 days from the date the first Purchase Payment is received, and then will be
INSTRUCTIONS invested according to your investment instructions.
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7. SYSTEMATIC / / I would like to make regular Purchase Payments from my checking or savings account. I have
INVESTING completed Form LPS-5318 and am sending it in with this application. (Not available for TSA or 457
Plans.)
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8. TRANSFERS / / I have chosen to allocate some or all of my initial Purchase Payment to the Dollar Cost Averaging
Fixed Account Option and elect to have monthly transfers made to the Portfolios listed below.
/ / I have read the information in the Prospectus about the following scheduled transfers and would
like to elect:
1. / / DOLLAR COST AVERAGING: I elect to transfer $_________ (minimum $50) or _______% from the
______________________________________ Portfolio / / monthly / / quarterly to the Portfolios
listed below.
2. / / APPRECIATION SWEEP ($10,000 minimum account balance required): I elect to have the
appreciation of the Money Market Portfolio transferred / / monthly / / quarterly / / annually
to the Portfolios listed below.
3. / / PORTFOLIO REBALANCING ($10,000 minimum account balance required): I elect to rebalance my
Portfolios / / quarterly / / semiannually / / annually.
____% SAFECO RST Bond ____% Dreyfus VIF Quality Bond
____% SAFECO RST Equity ____% Federated High Income Bond Fund II
____% SAFECO RST Growth Opportunities ____% Federated Utility Fund II
____% SAFECO RST Money Market ____% Fidelity VIP Growth
____% SAFECO RST Northwest ____% Fidelity VIP III Growth & Income
____% SAFECO RST Small Company Value ____% Fidelity VIP III Growth Opportunities
____% AIM V.I. Aggressive Growth ____% Franklin Small Cap Fund - Class 2
____% AIM V.I. Growth ____% Xxxxxxxx U.S. Government Fund -
____% American Century VP Balanced Class 2
____% American Century VP International ____% INVESCO VIF-Real Estate Opportunity Fund
____% Dreyfus IP MidCap Stock ____% X.X. Xxxxxx U.S. Disciplined Equity
____% Dreyfus IP Technology Growth ____% Xxxxxxx VLIF Balanced
____% The Dreyfus Socially Responsible ____% Xxxxxxx VLIF International
Growth Fund, Inc. ____% Xxxxxxxxx Developing Markets Securities
____% Dreyfus VIF Appreciation Fund - Class 2
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9. TELEPHONE I, _____________________________________________ , hereby authorize SAFECO Life Insurance Company
TRANSFER (SAFECO) to accept and act on telephone instructions from me or any person(s) listed below regarding the
AUTHORIZATION transfer of funds between, or change in the percentage of my allocations among, portfolios of my
variable annuity contract. This authorization will remain in effect until SAFECO receives written
revocation from me.
SAFECO will employ reasonable procedures to confirm that instructions communicated by telephone are
genuine. SAFECO reserves the right to refuse telephone instructions from any caller when unable to
confirm to SAFECO's satisfaction that the caller is authorized to give those instructions.
To transfer by telephone, call SAFECO at 1-877-4SAFECO (000-0000). All telephone transfer calls will
be recorded. You or your authorized third party will be required to provide the identification
information listed below. Written confirmation of transfer transaction(s) will be mailed to you.
Unless otherwise indicated, this form does not permit anyone else to exercise discretionary authority
to effect transactions on my behalf without obtaining my prior authorization. If you are unsure if you
have this authority, please consult your broker/dealer.
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PRINT OR TYPE FULL NAME OF AUTHORIZED THIRD PARTY
IDENTIFICATION INFORMATION:
My mother's maiden name is:___________________________________________ Account #:________________________
(if available)
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SIGNATURE OF OWNER DATE
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10. STATEMENT OF HAVE YOU RECEIVED A CURRENT PROSPECTUS? / / YES / / NO
OWNER(S)
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other
person files an application of insurance containing any materially false information or conceals for
the purpose of misleading, information concerning any fact material thereto commits a fraudulent
insurance act, which is a crime.
I declare that the statements and answers on this application are full, complete, and true, to the
best of my knowledge and belief, and shall form a part of the annuity contract issued hereon. I
understand and agree that any fees or taxes will be deducted from my contract value or purchase
payment, as applicable.
I understand that when contract values and annuity payments are based on investment performance of the
Separate Account, the dollar amounts cannot be predicted or guaranteed. I also understand that
withdrawals from the Guaranteed Interest Period Fixed Account Option before the end of the Guaranteed
Period will be subject to a market value adjustment that will increase or decrease the cash surrender
benefit. Variable annuity contracts should be purchased for long-term retirement purposes.
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Signature of Owner Signed in City, State
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Signature of Joint Owner (if applicable) Date
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11. TSA INFORMATION Employer Name _________________________________________________________________________________________
Address________________________________________________________________________________________________
Street City State Zip Code
Please verify that the TSA Plan Information Sheet is on file with the SAFECO Life Home Office. This
application cannot be processed without verification of Employer's eligibility to sponsor a 403(b)
Plan.
PLANS COVERED BY XXXXX:
This employee has satisfied all eligibility requirements to receive contributions under our plan.
Furthermore, Joint & Survivor Annuity option disclaimers (if required by plan) are on file with the
Plan Administrator.
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Plan Administrator Signature Date
CONTRIBUTION FREQUENCY:
/ / Annual (01) / / Bi-Weekly (26) Deductions will begin the month of:
/ / Quarterly (04) / / Weekly (52) _________________________________________________
/ / Monthly (12) / / 10 Pay Periods Month(s) to exclude:
/ / Semi-Monthly (24) _________________________________________________
/ / Other: ________________________________________ Contribution per pay frequency:
$____________________________________________
SOURCE OF CONTRIBUTION: Anticipated annual contributions:
/ / Employee Salary Reduction $____________________________________________
/ / Employer (Amount must be provided)
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12. REGISTERED To the best of my knowledge, the annuity applied for here / / DOES / / DOES NOT replace any life
REPRESENTATIVE insurance or annuity in this or any other company. I hereby certify that I witnessed the signature(s)
INFORMATION above and that the answers to the questions above are true to the best of my knowledge and belief.
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Registered Representative's Name Stat # %
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Registered Representative's Name Stat # %
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Agency State/Location ID #
( )
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Registered Representative's Signature Telephone Number
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