icc22r290final11-04x22ba






Linking/BIN/Brokerage Acct. Number (if applicable) Page 1 of 11 R290 06/23 Home Office:  Lansing, Michigan www.jackson.com ICC22 R290 Jackson   pre-assigned Contract Number (if applicable) APPLICATION FOR AN INDIVIDUAL SINGLE PREMIUM DEFERRED REGISTERED INDEX-LINKED ANNUITY (RILAXXX) Primary Owner First Name Middle Name Last Name Non-Natural Owner/Entity Name (if applicable) Social Security Number Phone Number (include area code) Individual/Joint Corporation/Pension PlanCustodian Government Entity Tax ID Numberor Trust Physical Address Line 1  Physical Address City State ZIP Mailing Address City State ZIP Physical Address Line 2 Mailing Address Line 1 Mailing Address Line 2 (mm/dd/yyyy)Date of Birth Email Address Country of Residence Sex Male FemaleU.S. Citizen Yes No MARKETING NAME    (06/23)  SM (no P.O. Boxes) Customer Care: 800-873-5654 Fax: 800-943-6761 Email: customercare@jackson.com First Class Mail: P.O. Box 30314 Lansing, MI 48909-7814 Overnight Mail: 1 Corporate Way Lansing, MI 48951 PLEASE PRINT  CLEARLY Type of Ownership: 





 






Page 2 of 11 R290 06/23ICC22 R290 First Name Middle Name Last Name Relationship to Owner Social Security Number Phone Number (include area code) Physical Address Line 1 Physical Address City State ZIP Physical Address Line 2 First Name Middle Name Last Name Social Security Number Physical Address Line 1 Physical Address City State ZIP Physical Address Line 2 Date of Birth (mm/dd/yyyy) First Name Middle Name Last Name Relationship to Primary Annuitant Social Security Number Phone Number (include area code) Physical Address Line 1  Physical Address City State ZIP Physical Address Line 2 Joint Owner Primary Annuitant Joint Annuitant Phone Number (include area code) (mm/dd/yyyy)Date of Birth Email Address (print clearly)Date of Birth (mm/dd/yyyy) Sex Male FemaleU.S. Citizen Yes No Country of Residence Sex Male FemaleU.S. Citizen Yes No Country of Residence Sex Male FemaleU.S. Citizen Yes No Country of Residence Joint Annuitant Not Applicable (no P.O. Boxes) (no P.O. Boxes) (no P.O. Boxes) Complete this  section if  different than  Primary Owner.  If Primary  Annuitant  section is left  blank, the  Annuitant will  default to the  Primary Owner. Complete this  section if  different than  Joint Owner. If  Joint Annuitant  section is left  blank, the Joint  Annuitant will  default to the  Joint Owner. In the case of  Joint Owners,  all  correspondence  and required  documentation  will be sent to  the address of  the Primary  Owner. 





 






Page 3 of 11 R290 06/23ICC22 R290 Beneficiary(ies) Primary % Percentage of Death Benefit First Name Middle Name Last Name Non-Natural Owner/Entity Name (if applicable) Phone Number (include area code) Physical Address Line 1 Physical Address City State ZIP Physical Address Line 2 Social Security/Tax ID Number Relationship to OwnerDate of Birth (mm/dd/yyyy) Primary % Percentage of Death Benefit First Name Middle Name Last Name Non-Natural Owner/Entity Name (if applicable) Phone Number (include area code) Physical Address Line 1 Physical Address City State ZIP Physical Address Line 2 Social Security/Tax ID Number Relationship to OwnerDate of Birth (mm/dd/yyyy) Primary % Percentage of Death Benefit First Name Middle Name Last Name Non-Natural Owner/Entity Name (if applicable) Phone Number (include area code) Physical Address Line 1 Physical Address City State ZIP Physical Address Line 2 Social Security/Tax ID Number Relationship to OwnerDate of Birth (mm/dd/yyyy) Contingent Contingent Sex Male Female Sex Male Female Sex Male Female (no P.O. Boxes) (no P.O. Boxes) (no P.O. Boxes) It is required for  Good Order  that the  Percentage of  Death Benefit  be whole  numbers and  must total  100% for each  beneficiary  type. If  Percentage of  Death Benefit is  left blank, all  beneficiaries  will receive  equal shares. Please use the  Beneficiary  Designation  Supplement  form (X3041)  for additional  beneficiaries. 





 






Tax Qualification Non-Tax Qualified Roth IRA Other: SEP Roth Conversion IRA - Traditional Stretch IRA Non-Qualified Stretch 403(b) TSA  10-Year Qualified Deferral For Stretch Deferrals, please indicate the deferral type and the deceased's information: Relationship to Current Owner/Applicant Date of Birth Date of Death  Stretch Roth IRA Premium Payment Check(s) ACH/Wire(s) $ $ Anticipated total amount from: $ $ Company Releasing Funds Account Number Full Partial Full Partial Maturity Date Transfer Type $ $ Anticipated Transfer Amount Please provide the following information if applicable: Jackson to request funds IRC 1035 Exchange Direct Transfer Non-1035 Exchange Non-Direct RolloverDirect Rollover Non-Qualified Plans: All Other Plans: Internal Transfer(s)/Death Claim Proceeds External Transfer(s) In-house funding - Select one: Page 4 of 11 R290 06/23ICC22 R290 Year:                      $ Year:                      $ Financial Professional or Owner to request funds Payment included Internal Transfer Death Claim Proceeds (mm/dd/yyyy) (mm/dd/yyyy) The Registered  Index-Linked  Annuity  Automatic  Withdrawal Request form  (R4370) is  required if a  Stretch  qualification is  elected. External  Transfers: The  Request for  Transfer or  Exchange of  Assets form  (X3783) must  be submitted if  Jackson is  to request  the release  of funds. For more than  two account  transfers,  please provide  account  information on  the Letter of  Instruction form  (X4250) and  submit with  application. Select payment method. Must select at least one: For IRA - Traditional or Roth IRA Tax Qualifications, please indicate tax contribution year(s) and amount(s). If the  year(s) is (are) not indicated, Jackson will default to the current tax year. We reserve the right to refuse a Premium payment that is comprised of multiple payments over a period of  time. If we permit you to make multiple payments as part of your Premium payment, the Contract will not  be issued until all such payments are received. We reserve the right to hold such multiple payments in a  non-interest bearing account until the Issue Date.  





 






Page 5 of 11 R290 06/23ICC22 R290 Statement Regarding Existing Policies or Annuity Contracts (Must select one) NoYes Are you replacing or changing an existing life insurance policy or annuity contract?  Telephone/Electronic Transaction Authorization Annuitization/Income Date Specify Income Date (mm/dd/yyyy) It is required for  Good Order  that this entire  section be  completed. Notice to Financial Professional: If the Applicant does have existing life insurance policies or annuity  contracts, you must present and read to the Applicant the Replacement of Life Insurance or Annuities form  (X0512 - state variations apply) and return the notice, signed by both the Financial Professional and  Applicant, with the Application. I (We) do have existing life insurance  policies or annuity contracts. I (We) do not have existing life  insurance policies or annuity contracts. I (We) certify that with regard to Jackson or any other company:   By checking " Yes," I (we) authorize Jackson to accept instructions to initiate or discontinue Periodic Reallocation Programs (Automatic Rebalancing, End-Term Performance Lock), initiate an Intra-Term Performance Lock or transfer Contract values between Contract Options via telephone, internet, or other electronic medium from me, or in the case of Joint Owners, from any Joint Owner, or from my (our) Financial Professional, subject to Jackson's administrative procedures. Do you consent to Telephone/Electronic Transaction Authorization?          Yes           No Jackson has administrative procedures that are designed to provide reasonable assurances that telephone/electronic transaction authorizations are genuine. If Jackson fails to employ such procedures, it may be held liable for losses resulting from a failure to use such procedures. I (We) release Jackson, its affiliates, subsidiaries, and agents from  all damages related in any way to its acting upon any unauthorized telephone/electronic instruction, where  Jackson's administrative procedures were properly followed. I (We) understand and agree that Jackson reserves the  right to terminate or modify these telephone/electronic privileges at any time, without cause and without notice to  me (us). To give consent to initiate partial withdrawals via telephone, internet, or other electronic medium, please  complete the Registered Index-Linked Annuity Telephone/Electronic Authorization Request form (R3782). If no election  is made,  Jackson will  default to  " No." If an Annuitization/Income Date is not specified, Jackson  will default to the Latest Income Date as shown in the  Contract. 





 






Page 6 of 11 R290 06/23ICC22 R290 Contract Options Periodic Reallocation Programs PLEASE NOTE: Contract Options are subject to availability. Automatic Rebalancing End-Term Performance Lock 1-Year    %Index Account Options S&P 500   Index BUFFER 10% 20% Cap Performance Boost Performance Trigger Cap 3-Year    % 6-Year    % Performance Trigger FLOOR 10% Cap 1-Year    %Index Account Options Russell 2000   Index BUFFER 10% 20% Cap Performance Boost Performance Trigger Cap 3-Year    % 6-Year    % Performance Trigger FLOOR 10% Cap Tell us how  you want  your annuity  Premium  invested.  Whole percentages only. TOTAL  ALLOCATION MUST EQUAL  100%. CONTRACT OPTIONS CONTINUED ON PAGE 7. Certain  broker-dealers  may limit the  Index Account  Options and/or  Fixed Account  under the  Contract. Please  see Applicant  Acknowledg- ments on page  9. Automatically transfer any positive Index Adjustments from the Index Account Option(s) to the 1-year Fixed Account Option on the Index Account Option Term Anniversary. Automatically rebalance Index Account Option and Fixed Account Option allocations on the Index Account Option Term Anniversary and/or the Contract Anniversary, as applicable, where more than one Contract Option has been elected. Note: Automatic Rebalancing will occur on an annual basis on each Contract Anniversary. Only eligible  Contract Options will proportionally reallocate based on the percentages You provide. Index Account Options  are only eligible to be included in rebalancing on their Index Account Option Term Anniversary. Please read the Important Information related to Periodic Reallocation Programs in the Notice to Applicant section on page 9. May select only one Periodic Reallocation Program. 





 






Page 7 of 11 R290 06/23ICC22 R290 Contract Options (continued from page 6)PLEASE NOTE: Contract Options are subject to availability. Fixed Account Option Fixed Account 1-Year    % 1-Year    %Index Account Options MSCI EAFE Index BUFFER 10% 20% Cap Performance Boost Performance Trigger Cap 3-Year    % 6-Year    % Performance Trigger FLOOR 10% Cap 1-Year    %Index Account Options MSCI Emerging Markets Index BUFFER 10% 20% Cap Performance Boost Performance Trigger Cap 3-Year    % 6-Year    % Performance Trigger FLOOR 10% Cap 1-Year    %Index Account Options MSCI KLD 400 Social Index BUFFER 10% 20% Cap Performance Boost Performance Trigger Cap 3-Year    % 6-Year    % Performance Trigger FLOOR 10% Cap Tell us how  you want  your annuity  Premium  invested. Whole percentages only. TOTAL  ALLOCATION MUST EQUAL  100%. Certain  broker-dealers  may limit the  Index Account  Options and/or  Fixed Account  under the  Contract. Please  see Applicant  Acknowledg- ments on page  9. 





 






Page 8 of 11 R290 06/23ICC22 R290 Electronic Delivery Authorization Do you consent to electronic delivery of documents? Yes No Transaction confirmations Other Contract-related correspondence ALL DOCUMENTS Contract and prospectus Disclosure documents Annual statements If no election  is made,  Jackson will  default to  " No." Check the box(es) next to the type of documents you wish to receive electronically. If electronic delivery is  authorized but no document type is selected, the selection will default to "All Documents." Please provide  one email  address and  print clearly. If you authorize  electronic  delivery but do  not provide an   email address  or the address  is illegible,  electronic  delivery  will  not be initiated. Registration at  jackson.com is  required for  electronic  delivery of  documents. Authorizing   electronic  delivery of  annual  statements will  automatically  enroll you to  receive  quarterly  summaries.  Quarterly  summaries are  only available  via electronic  delivery. My email address is:                                                                                                                                                I (We) will notify the Company of any new email address. Jackson offers the ability to receive documents via electronic delivery (e-delivery). This disclosure will help you  decide whether you would like to consent to e-delivery. If you do not consent to e-delivery, you will continue to  receive documents via physical mail. Please read this carefully and in its entirety. If you consent, Jackson will provide documents related to your Contract by e-delivery. Jackson will provide  documents via e-delivery as long as it is consistent with applicable state and federal law, delivery preferences are  updated, and the Contract is still active. For security purposes, if your jackson.com account is not accessed within  18 months, we may remove your registration and change your delivery method to physical mail. Any document we  send by e-delivery that complies with applicable law, will have the same force and effect as if that document were  sent in a paper form.  This consent covers all electronic documents and communications as related to any eligible* Contract(s) through  the Company, which may include, but are not limited to, applications, supplements, Contract delivery notices,  Contracts, prospectuses, prospectus supplements, statements of additional information, annual and semiannual  reports, confirmation statements, annual or quarterly statements, and any Contract-related correspondence  including claims and servicing correspondence. You may continue to receive some paper documents for compliance  reasons. When additional document types are available, they will be sent via e-delivery automatically if consent was  previously provided.  Please note election for electronic tax documents must be completed once you log onto your account on  jackson.com. The Company will notify you of the availability of your document(s) by email or attach your document(s) within the  email. Jackson will not charge a fee for this service. Please make sure a current email address is provided and  update your profile on jackson.com if your email address changes. Please login to your Contract on jackson.com  and access your Filing Cabinet to view your document(s) or click the link that will be provided in the email  notification in order to view the material.  To successfully receive electronic transmissions, your electronic device must have internet access, an active email  account, Adobe Acrobat Reader, and pop-up blockers turned off. Please note some internet browsers may not  function well with jackson.com. If a browser error occurs, use a different internet browser. If you do not already  have Adobe Acrobat Reader, it can be downloaded for free from www.adobe.com.  Paper copies of documents may be requested by calling the Customer Care Center, whether or not you consent or  revoke your consent for e-delivery, at any time for no additional charge. Consent can be revoked by updating your  preferences on jackson.com or by calling the Customer Care Center. If you choose to enroll in e-delivery, you consent to the terms outlined above for electronic transmissions.  *Eligible refers to Contracts that are currently inforce or that will be inforce and are available for electronic transmission.  





 






Applicant Acknowledgments ICC22 R290 Page 9 of 11 R290 06/23 Notice to Applicant 1. I (We) hereby represent to the best of my (our) knowledge and belief that each of the statements and  answers contained in this application are true, complete and correctly recorded. 2. I (We) certify that the Social Security or Taxpayer Identification number(s) shown above is (are) correct. 3. I (We) certify that the date of birth of the Owner and any Joint Owner, primary spousal Beneficiary, Annuitant  or Joint Annuitant, if applicable, stated in this application is (are) true and correctly recorded. 4. I (We) hereby represent to the best of my (our) knowledge and belief that I (we) have made an informed  decision to purchase this product and, if applicable, have reviewed the differences between this product and  my (our) original product. The product fits my (our) investment needs and objectives, liquidity needs, time  horizon, risk tolerance and my (our) general financial situation.  5. I understand the restrictions imposed by 403(b)(11) of the Internal Revenue Code. I understand the  investment alternatives available under my employer's 403(b) plan, to which I may elect to transfer my  contract value. 6. I (We) understand that while the values of the Contract may be affected by an external Index, the Contract  does not participate in any stock or equity investment. 7. I (We) understand that the capping component in this Contract may limit the Index Adjustment credited to  the Index Account Option value on each Index Account Option Term Anniversary, regardless of the  performance of the Indices. 8. I (We) have received the applicable current Buffers/Floors, Caps/Rates and any other Index Adjustment Factors  associated with this Contract. 9. I (We) understand that to the extent I (we) have been permitted to make a Premium payment comprised of  multiple payments over a period of time, my (our) Contract will not be issued until all such payments are  received, and all Premium payments will be held in a non-interest bearing account until the date my (our)  Contract is issued. 10. I (We) have been given a current prospectus for this registered index-linked annuity product.  11. I (We) understand that Jackson offers other annuities with similar features, limitations, minimum Caps/Rates  and charges. I (We) have discussed the alternatives with my (our) Financial Professional, including that similar  products with higher or lower Caps/Rates may be available through other broker-dealers. 12. I (We) understand and acknowledge that amounts payable under the Contract may be subject to a  Withdrawal Charge and/or a Market Value Adjustment(s), if applicable, which may cause the values to  decrease if withdrawn or annuitized prior to a specified date or dates as stated in the Contract. 13. I (We) acknowledge and represent that I (we) have executed this application, and that my (our) signature(s)  below (including my (our) electronic signature(s)) is (are) my (our) true and valid signature(s). I (We) further  authorize Jackson to accept any electronic signature(s) that I (we) may make to this application. 14. I (We) understand that certain broker-dealers may limit the Contract Options available under the Contract. I  (We) have discussed these limitations with my (our) Financial Professional and have been provided with a list  of Contract Options currently available for election through my (our) broker-dealer.  I (We) understand that  any application including an election of a Contract Option not available through my (our) broker-dealer will  not be accepted. I (We) understand that the Contract Options not available through my (our) broker-dealer  may be available through other broker-dealers. Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal  offense and subject to penalties under state law. Important Information related to Periodic Reallocation Programs: Periodic Reallocation Programs do not ensure a profit or protect against loss. Principal value and investment return  in the Index Account Options will fluctuate with changes in the elected tracked Index. When reallocated, Index  Account Option values may be more or less than the Index Return due to the application of Index Adjustments  associated with your elected crediting method. In addition, Index Account Option values on the date reallocated  may be more or less than they were on the date of original allocation due to changes in Index Return during the  elected Index Account Option term. Please see the prospectus for additional information related to Periodic  Reallocation Programs. 





 






Page 10 of 11 R290 06/23ICC22 R290 Owner's Signature Date Signed (mm/dd/yyyy) State Where Signed Owner's Title Date Signed (mm/dd/yyyy)Joint Owner's Signature Date Signed (mm/dd/yyyy) Date Signed (mm/dd/yyyy) Annuitant's Signature Joint Annuitant's Signature Applicant Signatures State Where Signed U.S. Tax Certifications Check this box if the IRS has notified you that you are subject to backup withholding.  (required if owned by an Entity) (if other than Owner) (if other than Joint Owner) Not FDIC/NCUA Insured    Not bank/CU guaranteed    May lose value Not a deposit    Not insured by any federal agency It is required for  Good Order  that all  applicable  parties to the  Contract sign  here. Required  replacement  form(s) must  be signed on  or before the  application  signature  date. Under penalties of perjury, I certify that: 1. My Social Security Number or Tax ID Number shown on this application is my correct taxpayer  identification number,  2. I am not subject to backup withholding,  3. I am a U.S. citizen or other U.S. person (including a U.S. resident alien), and 4. I am exempt from Foreign Account Tax Compliance Act (FATCA) reporting.  For items 3 and 4, if I am not a U.S. citizen, U.S. resident alien or other U.S. person, I am submitting the  applicable IRS Form W-8 to certify my foreign status and, if applicable, claim treaty benefits.  The Internal Revenue Service does not require your consent to any provision of this document other than  the certifications to avoid backup withholding. 





 






Financial Professional Acknowledgments and Signature I did not use sales material(s) during the presentation of this Jackson product to the applicant. ICC22 R290 Page 11 of 11 R290 06/23 Financial Professional # 1 Signature Date Signed (mm/dd/yyyy) First Name Middle Name Last Name Email Address Business Phone Number (include area code) Jackson Assigned ID Financial Professional # 2 Name Financial Professional # 3 Name Jackson Assigned ID Jackson Assigned ID Percentage Percentage % % Percentage % (print clearly) Extension Financial Professional # 4 Name Jackson Assigned ID Percentage % Program Options A B C D Financial Institution I certify that: Complete this  certification  regarding sales  material section  only if:   The applicant  has other  existing policies  or annuity  contracts AND  Will be either  terminating any  of those  existing policies  or using the  funds from  existing policies  to fund this  new Contract.  By signing this form, I certify that: 1. I am authorized and qualified to discuss the Contract herein applied for. 2. I have reviewed all of the applicant's information, and I believe that my recommendation to purchase this  annuity is in line with the applicant's financial situation and investment needs, and meets the appropriate  standard of care (i.e. suitability or best interest) based on the facts disclosed by said applicant. I also attest that I  have provided the applicant with all pertinent information about the product, including disclosure of risks  involved, allowing the applicant to make an educated and informed decision about this purchase. Based on my  completion of the required general annuity and/or Jackson product training, I believe this transaction is suitable  and in the best interest of the applicant given the applicant's financial situation and needs. 3. The applicable current Buffers/Floors, Caps/Rates and any other Index Adjustment Factors associated with this  Contract have been presented and explained to the applicant(s).  4. I have not made statements that differ from this material nor have I made any promises about the expected  future Index Account Option values of this Contract. 5. I have read Jackson's Position With Respect to the Acceptability of Replacements (XADV5790) and ensured that  this replacement (if applicable) is consistent with that position. 6. The applicant's Statement Regarding Existing Policies or Annuity Contracts has been answered correctly to the  best of my knowledge and belief. 7. The applicant's statement as to whether or not an existing life insurance policy or annuity contract is being  replaced or changed is true and accurate to the best of my knowledge and belief. 8. I have discussed all applicable limitations to Contract Option availability with the applicant and have provided  the applicant with a list of Contract Options currently available for election. Program Options Note: If no option is  indicated, the   designated  default will be  used.  If more than one Financial Professional is participating in a Program Option on this case, please provide the  additional Financial Professional names, Jackson Assigned IDs and percentages for each (Financial Professional # 1-4  totaling 100%). If Percentage is  left blank, all  Financial  Professionals  will receive  equal shares. All Financial  Professional  certifications,  licenses and  trainings must  be completed  prior to  application  execution.  In addition, copies of all approved sales material(s) used during the presentation were left with the applicant. I used only Jackson-approved sales material(s), including electronically presented materials, during the  presentation of this Jackson product to the applicant.