Post-Effective Amendment
Filing Table of Contents
Document/Exhibit Description Pages Size
1: 485BPOS American Forerunner Series 259 1.53M
6: EX-99.10(I) Consent of Deloitte & Touche 1 7K
7: EX-99.10(II) Consent of Sutherland & Asbill 1 6K
2: EX-99.4(V) Forms of Endorsement 29± 98K
3: EX-99.5(III) Form of Application 4± 23K
4: EX-99.7 Automatic Reinsurance Agreement 49 140K
5: EX-99.9 Opinion & Consent of Anne Goggin 2 9K
EX-99.5(III) — Form of Application
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Exhibit (5)(iii)
[NEW ENGLAND FINANCIAL LOGO] ADMINISTRATIVE OFFICE, NEW ENGLAND FINANCIAL
PO Box 14594 Des Moines Iowa 50306-3594
501 Boylston Street
Boston, Massachusetts 02116-3700
VARIABLE ANNUITY APPLICATION FOR COMPANY USE ONLY
TO NEW ENGLAND LIFE INSURANCE COMPANY (NELICO) No.________________________________
AMERICAN FORERUNNER SERIES VARIABLE ANNUITY APPLICATION
CLASS SELECTION: Select One Class -- If no class is selected, the Standard Class will automatically be chosen.
[ ] STANDARD CLASS [ ] P CLASS [ ] C CLASS [ ] L CLASS [ ] B PLUS CLASS*
*IF B PLUS CLASS IS CHOSEN, PLEASE COMPLETE THE BONUS DISCLOSURE FORM.
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1. ANNUITANT AND OWNER(S)
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ANNUITANT (Annuitant will be the Owner unless Owner section is completed.)
Name (First, Middle Initial, Last) Gender [ ] M [ ] F Date of Birth
______________________________________________________________________________ ____________________ __________________________
Street Address Social Security #
______________________________________________________________________________ __________________________________________________
City, State & ZIP Code E-mail Address Marital Status
_________________________________________________________________ _________________________________ __________________________
Home Telephone # Work Telephone # Relationship to Owner
____________________________________ __________________________________________ ______________________________________________
OWNER - (Complete if the Owner is different from the Annuitant.)
*If owner is a trust, please complete the trustee certification form.
Name (First, Middle Initial, Last)
TYPE: [ ] Individual [ ] Custodian [ ] Trust [ ] Corporation Gender [ ] M [ ] F Date of Birth
______________________________________________________________________________ ____________________ __________________________
Street Address Social Security # or Tax I.D. # (TIN)
______________________________________________________________________________ __________________________________________________
City, State & ZIP Code E-mail Address Marital Status
_________________________________________________________________ _________________________________ __________________________
Home Telephone # Work Telephone # Relationship to Annuitant
____________________________________ __________________________________________ ______________________________________________
JOINT OWNER - NON-QUALIFIED ONLY
Name (First, Middle Initial, Last) Gender [ ] M [ ] F Date of Birth
______________________________________________________________________________ ____________________ __________________________
Street Address Social Security #
______________________________________________________________________________ __________________________________________________
City, State & ZIP Code E-mail Address Marital Status
_________________________________________________________________ _________________________________ __________________________
Home Telephone # Work Telephone # Relationship to Owner
____________________________________ __________________________________________ ______________________________________________
(Note: If two people are named as Joint Owners, either Owner may exercise any and all rights under the contract unless the Owner
specifies otherwise in writing.)
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2. PRIMARY AND CONTINGENT BENEFICIARY(IES) IF OWNER IS A TRUST, THE TRUST MUST BE THE BENEFICIARY.
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Beneficiary Type Name (First, Middle Initial, Last) Relationship to Owner Social Security #
[ ] Primary [ ] Contingent _______________________________________________ ______________________ ________________________
[ ] Primary [ ] Contingent _______________________________________________ ______________________ ________________________
[ ] Primary [ ] Contingent _______________________________________________ ______________________ ________________________
(Note: To be used to determine whom will be paid/assume all rights under the contract on the Owner's death. The Owner's estate will
be paid/assume all rights if no Beneficiary is named. Not applicable to Annuitant's death if the Natural Owner and Annuitant are
different and the Annuitant predeceases the Owner. Payment/assumption will be made in equal shares to the survivors unless
otherwise specified in writing by the Owner. If the primary beneficiaries predecease the Owner, the contingent beneficiaries will
be paid/assume all rights. If more than three beneficiaries are named, attach a separate sheet.)
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3. CONTRACT APPLIED FOR:
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[ ] Non-Qualified [ ] IRA [ ] Roth IRA [ ] SEP [ ] TSA Transfer [ ] SIMPLE [ ] Qualified Plan _________ [ ] Other __________
NEA APP-1-02
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4. PURCHASE PAYMENT(S):
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Initial Purchase Payment $_______________ and/or transfers: $________________ Prior Tax Year __________ Current Tax Year __________
PAYMENT METHOD: [ ] Check [ ] Wire [ ] Draft (if new, please complete MSA or ACH application)
PAYMENT TYPE: [ ] 1035 Exchange [ ] Transfer [ ] Rollover [ ] Contribution
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5. REPLACEMENT (MUST BE COMPLETED)
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(A) DO YOU HAVE ANY EXISTING INDIVIDUAL LIFE INSURANCE OR ANNUITY CONTRACTS? [ ] Yes [ ] No
(B) WILL THE ANNUITY APPLIED FOR REPLACE OR CHANGE ONE OR MORE EXISTING ANNUITY OR LIFE INSURANCE CONTRACTS?
[ ] Yes [ ] No
(Note: Replacement includes any surrender, loan, withdrawal, lapse, reduction in or redirection of payments on an annuity or
life insurance contract in connection with this application.) If (b) is "Yes", applicable disclosure and replacement forms
must be attached)
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6. OPTIONAL RIDERS (AVAILABLE AT TIME OF APPLICATION AND MAY NOT BE CHANGED ONCE ELECTED. THERE ARE ADDITIONAL CHARGES FOR
THE RIDERS.)
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DEATH BENEFIT RIDERS (CHECK ONLY ONE OR NONE)
[ ] Annual Step Up [ ] Greater of Annual Step Up or 5% Annual Increase
OTHER RIDERS (CHECK ONE, BOTH OR NONE)
[ ] GMIB (Guaranteed Minimum Income Benefit)* [ ] GMAB (Guaranteed Minimum Account Balance)
[ ] Earnings Preservation Benefit Rider
*The GMIB has limited usefulness in connection with tax-qualified contracts, such as IRAs, because if the GMIB is not
exercised on or before the date of required minimum distributions must begin under a qualified plan, the certificate
owner or beneficiary might be unable to exercise the GMIB benefit under the rider due to the restrictions imposed by the
minimum distribution requirements. If you plan to exercise the GMIB after your required minimum distribution beginning
date under an IRA, you should consider whether the GMIB is appropriate for your circumstances. You should consult your
tax advisor.
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7. AUTHORIZATION AND SIGNATURE(S)
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(A) NOTICE TO APPLICANT(S)
FLORIDA RESIDENTS ONLY Any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a statement
of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third
degree.
ARKANSAS, DISTRICT OF COLUMBIA, KENTUCKY, LOUISIANA, MAINE, NEW MEXICO, OHIO, PENNSYLVANIA AND TENNESSEE RESIDENTS ONLY Any
person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
submits a claim 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 and subjects such person to criminal and
civil penalties.
NEW JERSEY RESIDENTS ONLY Any person who includes any false or misleading information on an application for an insurance
policy is subject to criminal and civil penalties.
ANNUITY PAYMENTS OR SURRENDER VALUES, WHEN BASED UPON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE
AND ARE NOT GUARENTEED AS TO A FIXED DOLLAR AMOUNT.
(B) SIGNATURES I hereby represent my answers to the above questions to be correct and true to the best of my knowledge and
belief, the answers recorded are true and complete. My agreement in writing is required to any change made by the
Company as to information in the Application.
LOCATION WHERE THE APPLICATION IS SIGNED___________________________________________________________________________________________
City & State
___________________________________________________________________________________________________________________________________
Signature of Owner Date
___________________________________________________________________________________________________________________________________
Signature of Joint Owner Date
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8. REPRESENTATIVE INFORMATION
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STATEMENT OF REPRESENTATIVE All answers are correct to the best of my knowledge. I have provided the Proposed Owner with the
American Forerunner Series Prospectus prior or at the time he/she completed the application form.
Do you have reason to believe that the replacement or change of any existing insurance or annuity may be involved?
[ ] Yes [ ] No
___________________________________________________________________________________________________________________________________
Signature of Representative Date
Printed Representative Name Phone # State License I.D. #
___________________________________________________________________________________________________________________________________
Accepted by Company at the Administrative Office by ________________________________________ _______________
Principal Signature Date
NEA APP-1-02
8 Subsequent Filings that Reference this Filing
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