EX-5 4 application.htm VARIABLE ANNUITY APPLICATION application.htm

 
NEA
Valuebuilder*
Program
  
Nationwide Life Insurance Company
NEA Service Center-One Nationwide Plaza 2-17-03
P.O. Box 182437, Columbus, Ohio 43218-2437
1-800-325-6434

CONTRACT OWNER (Print Name)
    
BIRTHDATE
  
 
    
 
  
Address
    
Soc. Sec. No.
o o o o o o o o o
 
 
  
 
  
 
PHONE #
  
E-mail address
  
 
    
 
 
DESIGNATED ANNUITANT (Print Name)
  
Sex
 o M
o F

Address
    
Birthdate
  

   
Soc. Sec. No.
o o o o o o o o o
   
 
  
School District (Employer's) Name/Address
    

School Bldg. Name/Address
  
 
          
 
  
Beneficiary (Print)
  
SSN
  
Relation
  
% To Rec.
 
Beneficiary (Print)
  
SSN
  
Relation
  
% To Rec.
 
Contingent Beneficiary
  
SSN
  
Relation
  
% To Rec.
 
Contingent Beneficiary
  
SSN
  
Relation
  
% To Rec.
 
ANNUITY PURCHASE PAYMENTS:  First Purchase Payment $ ______________, if submitted herewith. Premium. Amount $  per pay multiplied by ____ pays per year $ _________________ Annual Premium.
PURCHASE PAYMENT ALLOCATION: (must total 100%)            
               
AIM Variable Insurance Funds, Inc.   Fidelity Variable Insurance Products Fund.   Janus Aspen Series
o 
% AIM V.I. Capitals Appreciation Fund: Series I
  
o 
% VIP Equity-Income Portfolio: Initial Class
  
o 
% International Growth Portfolio: Service Shares
o 
% AIM V.I. International Growth Fund: Series I
  
o 
% VIP High Income Portfolio: Initial Class
      
            Neuberger Berman Advisers Management Trust
American Century Variable Pottfolios, Inc.   Franklin Templeton Variable Insurance Products Trust  
o 
%AMT Balance Prtfloio
o 
% VP Balanced Fund: Class I
  
o 
% Templeton Foreign Securities Fund: Class I
    
%Strong opprtuni Fund II. Inc.
o 
% VP Income & Growth Fund: Class I
            
            Nationwide Life Insurance Co
Dreyfus        
o 
% Fixed Account
o 
% Dreyfus Stock Index Fund, Inc.: Initial Shares
   Gartmore Variable Insurance Trust (GVIT)      
o 
% Dreyfus Socially Responsible Growth Fund, Inc.
  
o 
% Federeated GVIT High Income Bond: Class I
      
     
o 
% GVIT Government Bond: Class I
      
Dreyfus Variable Investment Fund  
o 
% GVIT Money Market: Class I
      
o 
% Appreciation Portfolio
  
o 
% GVIT Nationwide®: Class I
      
o 
%Developing Leaders Portfolio: Initial Shares
            
o 
% Quality Bond Portfolio.
            
 
 
ANNUITY COMMENCEMENT DATE:
    
OPTIONAL ANNUTIY FORM ELECTED:
The First Day of
      
Unless otherwise indicated, I hereby elect the Life Annuity with 120 Monthly payments guaranteed.
CHECK PLANT TYPE: o IRA   o 401(K)   o Roth IRA  o 403(b)   o SEP-IRA   oNon-Qualified
    
o Joint and Last Survivor Annutiy.
Year for which contribution is applied        Second Person    
Please attach appropriate agreements.
    
Birthdate            
 
Relationship
   
Is this a rollover/transfer? Yes o  No   o
    
o 120 or o 140 Monthly Payments of Life
If yes, identify source
    
Will the annuity applied for replace existing annuity or life insurance?
 
      
oYes     o No         If Yes, explain:
REMARKS:
 
 
 
TELEPHONE EXCHANGE PRIVILEGE: I authorize the Company to make exchanges among the above Accounts based upon my telephone instructions. I understand and agree that (I) the Company will not be liable for any loss, liability, cost, or expense for acting in accordance with my instructions; (ii) exchanges will be made in accordance with procedures established by the Company (to be provided with the Contract); and (iii) the telephone exchange privilege may be suspended at any time by the Company or myself within 30 days of written notice.
I hereby represent my answers to the above questions to be correct and true to the best of my knowledge and belief and agree that this application shall be a part of any annuity contract issued by the Company. I UNDERSTAND THAT ANNUITY PAYMENTS AND SURRENDER VALUES, WHEN BASED UPON INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO A FIXED DOLLAR AMOUNT. RECEIPT OF A CURRENT VARIABLE ANNUITY PROSPECTUS IS HEREBY ACKNOWLEDGED.
 
o Please send me a copy of the Statement of Additional Information to the prospectus.

SIGNED AT:
      ON
 
 
(City/State)
    
(Date)

APPLICANT:
    
WITNESS:
  
 
(Signature of Applicant)
    
(Print Agent Name and No.)

AGENT'S TELEPHONE #:
      
 
    
(Signature of Agent)
   
AGENT:
Do you have reason to believe the Contract applied for is to replace existing annuities or insurance owned by the annuitant?
 
o Yes
o No
 
    
 
  
General Agent:
    
Principal Office:
  

City
     
State
     
Zip
     
Branch Office Location