Exhibit 4(d)


 


	
  

  	
   

  	
  Protective
  Life Insurance Company

  
	
   

  	
  Home Office: Nashville
  Tennessee

  
	
   

  	
   

  
	
   

  	
  Please send the
  application and check to:

  
	
   

  	
  Overnight

  	
  Postal Mail

  
	
   

  	
  Annuity New Business

  	
  Annuity New Business

  
	
   

  	
  2801 Highway 280 South

  	
  P.O. Box 10648

  
	
  Modified Guaranteed Annuity Application

  	
   

  	
  Birmingham, AL 35223

  	
  Birmingham, AL 35202-0648

  



 


	
  Owner/Participant 1

  	
  Name, Street, City, State, ZIP

  	
   

  	
  o  Male

  	
   

  	
  o  Female

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  Birthdate 

  	
   

  	
           /        /              

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
  M M 
  D D  Y Y Y Y

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  Tax ID/SSN

  	
   

  	
                                          

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Owner/Participant 2

  	
  Name, Street, City, State, ZIP

  	
   

  	
  o  Male

  	
   

  	
  o  Female

  
	
  (if applicable)

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  Birthdate 

  	
   

  	
           /        /              

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
  M M 
  D D  Y Y Y Y

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  Tax ID/SSN

  	
   

  	
                                          

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Annuitant

  	
  Name, Street, City, State, ZIP

  	
   

  	
  o  Male

  	
   

  	
  o  Female

  
	
  (if different than Owner/Participant 1)

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  Birthdate 

  	
   

  	
           /        /              

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
  M M 
  D D  Y Y Y Y

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  Tax ID/SSN

  	
   

  	
                                          

  
							



 


Primary
Beneficiary  (if there is no surviving
Owner)


 




	
  Name

  	
   

  	
  Relationship

  	
   

  	
  %

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  






 


Use
“Special Remarks” for additional Primary Beneficiary information.


 


Contingent
Beneficiary


 




	
  Name

  	
   

  	
  Relationship

  	
   

  	
  %

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  






 


Use
“Special Remarks’ for additional Contingent Beneficiary information.


 


	
  Total Annuity Deposit:

  	
   

  	
  $                                  

  	
   

  	
  Guaranteed Period:

  	
   

  	
                          years.

  
	
  (min. $25,000)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  



 


	
  Funding:

  	
   

  	
  o Cash

  	
   

  	
   ̈ 1035 Exchange

  	
   

  	
  o Direct Rollover

  	
   

  	
  o Indirect Rollover

  	
   

  	
  o Transfer

  
	
  (choose one)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  



 


For 1035 Exchanges,
Rollovers and Transfers, only:


·      Estimated total amount exchanged or
transferred:  $                                    


·      Rate Lock?


 ̈  Yes,
please lock the current interest rates for 60 days.


 ̈  No, please use the interest rate
in effect as of the date the funds are received at Protective.


Important information about the
Rate Lock.  If you select “Yes” and we receive the funds
within 60 days of the date we received this application, we will apply the
rates in effect on the date we received the application (regardless of the
rates in effect when we receive the funds). 
If you select “No”, or if we receive the funds after the 60-day Rate
Lock period, we will apply the rates in effect on the date we receive the
funds.


 


	
  Plan Type:

  	
   

  	
   ̈ Non-Qualified

  	
   

  	
   ̈ Traditional IRA

  	
   

  	
   ̈ Roth IRA

  	
   

  	
   ̈ Other                       

  
	
  (choose one)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  



 


If an IRA purchase payment includes new
contributions, please complete:


	
  $                       (Amount)
                        (Current Tax Year)

  	
   

  	
  $                       (Amount)
                        (Previous Tax Year)

  



 


	
  Replacement & Other:

  	
   

  	
   

  	
   

  	
   

  
	
  ·

  	
   

  	
  Do you currently have an annuity contract or life insurance policy?

  	
   

  	
   ̈ Yes

  	
   

  	
   ̈ No

  
	
  ·

  	
   

  	
  Will this annuity change or replace an existing life insurance policy
  or annuity contract?

  	
   

  	
   ̈ Yes

  	
   

  	
   ̈ No

  
	
   

  	
   

  	
  (If yes, please provide the company name and
  policy or contract number in “Special Remarks”.)

  	
   

  	
   

  	
   

  	
   

  
	
  ·

  	
   

  	
  Have you purchased any other Protective Life annuity contracts this
  calendar year?

  	
   

  	
   ̈ Yes

  	
   

  	
   ̈ No

  



 


An annuity contract is not a deposit or obligation of, or guaranteed
by, any bank or financial institution. 
It is not insured by the Federal Deposit Insurance Corporation or any
other government agency and is subject to investment risk, including the
possible loss of principal.


 


	
  IPD-2081

  	
   

  	
  ST  3/09

  



 

















 


NOTICE TO RESIDENTS OF AZ: On written request you may ask us to provide
you within ten business days, or 30 calendar days if you are 65 or older,
additional factual information regarding the benefits and provisions of this
Contract. If for any reason you are not satisfied, you may cancel the Contract
within that period by returning the Contract to our office, or the agent who
sold it with a written request for cancellation. Return of this Contract by
mail is effective on receipt by us. The returned Contract will be treated as if
we had never issued it.  We will promptly
return your Purchase Payment.


 


NOTICE TO RESIDENTS OF CA (AGE 60 AND
OLDER): YOU HAVE PURCHASED AN ANNUITY CONTRACT. REVIEW IT
CAREFULLY FOR LIMITATIONS. YOU MAY CANCEL THE CONTRACT WITHIN 30 DAYS OF
THE DATE YOU RECEIVE IT BY RETURNING IT TO THE INSURANCE COMPANY OR THE AGENT
WHO SOLD YOU THE CONTRACT. WE WILL REFUND YOUR PREMIUM. AFTER 30 DAYS,
CANCELLATION OF THE CONTRACT MAY RESULT IN A SUBSTANTIAL PENALTY, KNOWN AS
A SURRENDER CHARGE.


 


NOTICE TO RESIDENTS OF CO: It is unlawful to knowingly provide false, incomplete
or misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company.  Penalties may include imprisonment, fines,
denial of insurance and civil damages. 
Any insurance company or agent of an insurance company who knowingly
provides false, incomplete or misleading facts or information to a policy
holder or claimant for the purpose of defrauding or attempting to defraud the
policy holder or claimant with regard to a settlement or award payable from
insurance proceeds shall be reported to the Colorado Division of Insurance
within the Department of Regulatory agencies.


 


NOTICE TO RESIDENTS OF FL:  ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE
AN INSURER, FILES A STATEMENT OF CLAIM OR APPLICATION CONTAINING ANY FALSE,
INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY IN THE THIRD DEGREE.


 


NOTICE TO RESIDENTS OF NJ:  Any
person who includes any false or misleading information on an application for
an insurance policy is subject to criminal and civil penalties.


 


NOTICE TO RESIDENTS OF AR, DC, KY, LA, ME, MD, NM, OH,
OK, PA AND TN:  Any person who knowingly and with intent to
defraud any insurance company or other person, files an application for
insurance or statement of 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.


 


Special
Remarks


 


 


NOT INSURED BY ANY GOVERNMENT AGENCY ·  NO BANK GUARANTEE · NOT A DEPOSIT


 


I
understand this application will become part of the annuity contract.  The information I provided is true and
correct to the best of my knowledge and belief.  The Company deems my statements as
representations and not warranties.  The
Company may accept instructions from any Owner/Participant on behalf of every
Owner/Participant.  If this application
is declined, the Company shall have no liability except to return the annuity
deposit. 


 


I understand the Contract/Certificate contains a market value
adjustment.


 


	
  Application
  signed at: 

  	
   

  	
   on

  	
   

  
	
   

  	
  (City and State)

  	
   

  	
  (Date)

  



 


	
  Owner/Participant
  1:

  	
   

  	
   

  	
  Owner/Participant
  2:

  	
   

  



 


	
  Any
  Owner/Participant daytime phone #:

  	
   

  	
   

  	
  Annuitant:

  	
   

  
	
   

  	
   

  	
   

  	
  (If not
  an Owner/Participant)

  



 


Federal law requires the following
notice:  We may request or obtain
additional information to establish or verify your identity.


 


Producer
Report


 


	
  To the best of your
  knowledge and belief, does the applicant have any existing life insurance
  policy or annuity contract?

  	
   

  	
  o  Yes

  	
   

  	
  o  No

  
	
  To the best of your
  knowledge and belief, does this annuity purchase change or replace any
  existing annuity or life insurance?

  	
   

  	
  o  Yes

  	
   

  	
  o  No

  
	
  I have given a current
  Prospectus to the Owner/Participant named in this application.

  	
   

  	
  o  Yes

  	
   

  	
  o  No

  



 


I determined the suitability of this annuity
product to the applicant’s financial objectives and situation by inquiring into
the applicant’s:


 




	
  o  financial status

  	
   

  	
  o  tax status

  	
   

  	
  o  investment objectives

  	
   

  	
  o  other relevant information

  






 


	
  * Comments:

  	
   

  



 


	
  Type of unexpired
  government-issued photo I.D used to verify the applicant’s identity?

  	
   

  	
    #

  	
   

  



 


I certify that I have truly and accurately
recorded on this application the information provided to my by the applicant.


 


	
  Sign Producer Name:

  	
   

  	
   

  	
  Print Producer Name:

  	
   

  
	
  Producer #:

  	
   

  	
   

  	
  Agency /Brokerage:

  	
   

  
	
  Producer Phone #:

  	
   

  	
   

  	
  FL Lic. # (if applicable)