exv99w5wa

Exhibit 99(5)(a)


		q P.O. Box 5308 For Institutional Sales Cincinnati, OH 45201
The Ohio National Life Insurance Company Express mail address: One Financial Way, Cincinnati, Ohio 45242		q P.O. Box 5375 For Career and PGA Cincinnati, OH, 45201

ONcore Variable Annuity Application

1.		ONcore Product Name

2.		Annuitant



First Name	Middle	Last


				( )

Street Address	City	State	ZIP	Phone


SS#/Tax ID#: ___ ___ ___ ___ ___ ___ ___ ___ ___		Sex: q M q F Date of Birth: ____ — ____ — _________


3a.	Owner (If different than Annuitant)


	First Name		Middle


	Last


	Street Address


	City	State	ZIP
	( )

	Phone

	SS#/Tax ID# ___ ___ ___ ___ ___ ___ ___ ___ ___

	Sex: q M q F Date of Birth: ____ — ____ — ____


3b.	Joint Owner (If applicable) Owner’s Spouse? q Yes q No


	First Name		Middle


	Last


	Street Address


	City	State	ZIP
	( )

	Phone

	SS#/Tax ID# ___ ___ ___ ___ ___ ___ ___ ___ ___

	Sex: q M q F Date of Birth: ____ — ____ — ____

Beneficiary (If you need to provide additional information use Special Requests, Section 13, or enclose a signed letter of instruction.)



Beneficiary Name	q Primary		q Contingent


Street Address


City	State		ZIP

		( )

Date of Birth		Phone


Relationship to Annuitant



Beneficiary Name	q Primary		q Contingent


Street Address


City	State		ZIP

		( )

Date of Birth		Phone


Relationship to Annuitant

Optional Riders

	5a.		Living Benefit Riders

			Guaranteed Lifetime Withdrawal Benefit (GLWB) Rider with Investment Restrictions or Asset Allocation Models q Yes — Single Life q Yes — Joint Life (Complete Section 11a and 11b1 or 11b3.)

			Guaranteed Principal Protection (GPP) Rider q Yes (Not available with GLWB)

			If you selected the GPP Rider, you must allocate your purchase payments to a Model in 11b1(either directly or via DCA).

	5b.		Death Benefit Riders (Only one death benefit can be chosen with GLWB.)

			Annual Step-Up Death Benefit Rider q Yes

			Guaranteed Minimum Death Benefit Rider (GMDBR 80) q Yes (Not available with GLWB)

			Gain Enhancement Benefit Rider (GEB Plus & GEB) q 100% (Not available with GLWB)

q 50% (Not available with GLWB)

			Premium Protection Death Benefit Rider q Yes (Only available with GLWB)

			Premium Protection Plus Death Benefit Rider q Yes (Only available with GLWB)

FORM 4896 REV. I/II

Initial Purchase Payment


		o Amount with application $		o 1035 exchange/estimated transfer $

Type of Plan o Non-qualified o Qualified (For qualified plans, select type of plan and payment type below.)


o TSA/403(b)	o 401(k)	o SEP-IRA	o Roth IRA	o Roth Conversion

o IRA	o 457	o SIMPLE IRA	o Pension/Profit Sharing	o Other


		Payment Type:

		o Rollover (Plan Distribution)		o Contribution

		o Transfer (Attach transfer form(s).)		$ for tax year ; $ for tax year

8.		Replacement

		Do you have an existing life insurance policy or an annuity? o Yes o No

		Will the purchase of this annuity replace or change an existing life insurance policy or an annuity? o Yes o No

		(If yes, or 1035 exchange, write insurance company name and contract number in Special Requests, Section 13, and attach any required state replacement and/or transfer forms.)


9.		Rebalancing o Yes

		You must allocate to two or more Variable Subaccounts to elect rebalancing.

		Frequency: (Choose one.) o Quarterly o Semi-Annually o Annually

		If this box is checked, Variable Subaccounts will be rebalanced to the allocation percentages on this application (unless changed after issue of contract). Rebalancing does not apply to the Fixed Accumulation Account or to the Dow Subaccounts. Certain riders require rebalancing which we will do automatically. The Subaccounts in any Model are also automatically rebalanced quarterly.


10.		Systematic Withdrawals

		I (we) wish to start a series of withdrawals from the contract issued pursuant to this application as indicated below (surrender charges may apply, see contract). I understand that it may take up to 30 days to process my systematic withdrawal request.


		Select payout option:		Select frequency of payments:
		o 10% of the account value		o Monthly
		o $ flat dollar amount not to exceed 10% of account value		o Quarterly
		o % based on rider		o Semi-Annually
				o Annually
		o 72(t) (Form V-4633 must be submitted for 72(t)).

		Any withdrawals under $500 require EFT (Electronic Funds Transfer).

		Payment Schedule:

		o As soon as possible (if current funds are being dollar cost averaged, the first payment will occur immediately following the initial DCA transfer.)


o /	/
Month	Day	Year

		Where?

		o Via EFT to my bank account

		o Checking Account (Complete section below and attach a voided check.)

		o Savings Account (Attach a voided, pre-coded deposit slip.)

		Account Number Bank Telephone Number

		Bank Name

		Bank Address

		ABA Routing Number

		o Directly to my address of record

		Federal Income Tax Withholding Election

		If you do not select an option below, we are required to withhold at least 10% of the taxable amount.

		o A. I DO NOT want to have federal income tax withheld from my withdrawals.

		o B. I DO want to have ___% federal income tax withheld from my withdrawals (10% minimum).

FORM 4896 REV. I/II

11a.

Allocation of Purchase Payments (Choose one in 11a and complete 11b as directed.)

	o		100% Dollar Cost Averaging (DCA) (Not available with all products.) (For Allocations from DCA, indicate in 11b2.)

	I/we understand that the DCA account value must be at or above the amount that will permit the DCA transfers requested; otherwise these transfers will end. This request is in lieu of the requirement for individual written transfer requests. I/we may also change or terminate these transfers by written notice to The Ohio National Life Insurance Company. (You may not transfer from the DCA Account to the Fixed Accumulation Account.)


100% Allocation to DCA	o 6 Month DCA Account — Monthly	o 12 Month DCA Account — Monthly
	o 6 Month DCA Account — Quarterly	o 12 Month DCA Account — Quarterly

	o		100% Immediate Allocation of Purchase Payments to Fixed/Model or Fixed/Variable Subaccounts

			_____ % Allocation to Fixed Accumulation Account (Not available with GLWB Riders. Not available with all products.)

			_____ % Allocations to Model, Variable Subaccounts or Investment Restrictions (Complete 11b1, 11b2 or 11b3.)

	o		Mixed DCA (less than 100% to DCA) and Immediate Allocations to Model, Variable Subaccounts or Investment Restrictions

			_____ % Allocation to DCA (Not available with all products.)


o 6 Month DCA Account — Monthly		o 12 Month DCA Account — Monthly
o 6 Month DCA Account — Quarterly		o 12 Month DCA Account — Quarterly

			_____ % Fixed Accumulation Account (Not available with GLWB Riders. Not available with all products.)

			_____ % Immediate Allocations to Model, Variable Subaccounts or Investment Restrictions (Complete 11b1, 11b2 or 11b3.)

			Total of Allocation to DCA and Allocations above must be 100% (If you choose to DCA transfer into an Asset Allocation Model, indicate Model in 11b1.)

11b.

Complete appropriate section(s) below as instructed in 11a.

b1.

Asset Allocation Models (You may only be in one Model at any point in time. If you want to take advantage of dynamic models, you must complete Form 7215, Asset Allocation Advisory Agreement.) Neither Model 1 nor Model 5 may be selected with Guaranteed Lifetime Withdrawal Benefit Rider.


o Model 1 — Conservative	o Model 3 — Balanced	o Model 5 — Growth
o Model 2 — Moderately Conservative	o Model 4 — Moderate Growth

b2.

Variable Subaccounts/DCA (No more than 18 different Variable Subaccounts may be selected. At least 1% of your initial purchase payment must be allocated for each Variable Subaccount selected.)

Variable Subaccounts

DCA Transfers to:

Total must be 100%

	b3.		Investment Restrictions (If you have selected a rider with Investment Restrictions and you choose to DCA transfer into the Investment Restrictions, indicate Investment Restrictions in section11b3.

			Note: Minimum and Maximum Percentages indicated in each Category. With Investment Restrictions, no more than 18 different Variable Subaccounts may be selected within all the Categories. Category Totals must equal 100%. At least 1% of your initial purchase payment must be allocated for each Variable Subaccount selected.

FORM 4896 REV. I/II

Category 1 Subaccounts — Minimum 30% Maximum 60%

TOTAL ALLOCATION


Morgan Stanley UIF Core Plus Fix Inc Cl II			%
Ohio National Bond			%
Ohio National Money Market			%

TOTAL ALLOCATION


PIMCO VIT Real Return Admin			%
PIMCO VIT Total Return Admin			%
Total Allocated			%

Category 2 Subaccounts — All Amounts Not Allocated to Categories 1, 3, or 4, up to a Maximum 70%

TOTAL ALLOCATION


Dreyfus VIF Appreciation Svc			%
Federated Strategic Value			%
Fidelity VIP Contrafund Svc2			%
Fidelity VIP Equity-Income Svc2			%
Fidelity VIP Growth Svc 2			%
First Trust Target Equity/Income			%
First Trust Target VIP			%
Franklin Flex Cap Growth Securities Cl2			%
Franklin Income Securities Cl4			%
Franklin VIP Founding Funds Alloc Fund Cl4			%
Goldman Sachs VIT Strategic Growth Svc			%
Goldman Sachs VIT Large Cap Value Svc			%
Goldman Sachs VIT Structured U.S. Eq Svc			%
ICON Balanced			%
ICON Income Opportunity			%
ICON U.S. Equity			%
Ivy Funds VIP Asset Strategy			%
Janus Aspen Balanced Svc			%

TOTAL ALLOCATION


Janus Aspen Janus Portfolio Svc			%
Lazard Retirement U.S. Strategic Eq Svc			%
Legg Mason Equity			%
Legg Mason Equity Inc Builder ClI			%
Legg Mason Fundamental All Cap Value ClI			%
Legg Mason Large Cap Value ClI			%
MFS VIT Invstrs Grth Stock Series -SC			%
MFS VIT Total Return — SC			%
Morgan Stanley UIF Capital Grwth Cl II			%
Ohio National Nasdaq 100 Index			%
Ohio National S&P500 Index			%
PIMCO VIT Global Bond Admin			%
Prudential Series Fund Jennison			%
Prudential Series Fund Jn 20/20 Focus			%
Suffolk Bristol			%
Suffolk Bristol Growth			%
Suffolk Omni			%
Templeton Foreign Securities Cl4			%
Total Allocated			%

Category 3 Subaccounts — Maximum 25%

TOTAL ALLOCATION


Federated High Income Bond			%
Federated International			%
Federated Kaufmann Fund II Svc			%
Fidelity VIP Mid-Cap Svc2			%
Invesco VK VI Intl Growth Equity Series II			%
Janus Aggressive Growth			%
Janus Aspen Overseas Svc			%


*		JPMorgan Subaccounts not available with ONcore Lite II or Wrap

TOTAL ALLOCATION


Janus Aspen Worldwide Svc			%
Jennison Capital Appreciation			%
JPMorgan Mid-Cap Value*			%
Lazard Retirement International Eqty Svc			%
MFS VIT Mid Cap Growth — SC			%
Neuberger Berman AMT Regency S Cl			%
Goldman Sachs Mid Cap Opportunity			%
Total Allocated			%

Category 4 Subaccounts — Maximum 15%

TOTAL ALLOCATION


Eagle Capital Growth			%
Federated Intl Small-Mid Company			%
Fidelity VIP Real Estate Svc2			%
Ivy Funds VIP Science and Tech			%
Ivy Global Natural Resources			%
Janus Small Cap Growth			%
JPMorgan Small Cap Core*			%
Lazard Retirement Emerging Mrkts Eq Svc			%


*		JPMorgan Subaccounts not available with ONcore Lite II or Wrap

TOTAL ALLOCATION


Lazard Retirement U.S. Small-Mid Cap Eq Svc			%
MFS VIT New Discovery Series — SC			%
Morgan Stanley UIF US Real Estate Cl II			%
Neuberger Berman Millennium			%
PIMCO CommodityRealReturn Stra Admin			%
Royce Micro-Cap Inv Cl			%
Royce Small-Cap Inv Cl			%
Suffolk Bryton Growth			%
Total Allocated			%

Category Totals Must Equal 100%

Category 1

Category 2

Category 3

Category 4

Total Must Equal 100%


FORM 4896 REV. I/II				Subaccount List Effective 1/7/11

12.		Portfolio Transfer Authorization (Owner/Owners must initial.) _______ _______

		By initialing, The Ohio National Life Insurance Company is authorized and directed to act on telephone instructions, written instructions except electronic mail, and/or Internet instructions from any person(s) who can furnish proper identification. The Ohio National Life Insurance Company will use reasonable procedures to confirm that these instructions are authorized and genuine. As long as these procedures are followed, The Ohio National Life Insurance Company, affiliates, directors, trustees, officers, employees, representatives and/or agents, will be held harmless for any claim, liability, loss or cost.

		I/we authorize you to allow my registered representative/agent to make telephone instructions, written instructions except electronic mail, and/or Internet transfers on my behalf, unless “No” is checked. o No

13.		Special Requests

14.		Statement of Applicant

		All statements made in this application are true to the best of my/our knowledge and belief, and the answers to these questions, together with this agreement, are the basis for issuing the contract. I/we agree to all terms and conditions as shown on the front and back. I/we further agree that this application shall be a part of the annuity contract, and verify my/our understanding that ALL PAYMENTS AND VALUES PROVIDED BY THE CONTRACT, WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT, ARE VARIABLE AND NOT GUARANTEED AS TO DOLLAR AMOUNT. THE OWNER ACKNOWLEDGES RECEIPT OF THE CURRENT PROSPECTUS FOR THE SEPARATE ACCOUNT APPLICABLE TO THE CONTRACT AND ALL AVAILABLE UNDERLYING PORTFOLIOS. I/we agree that no one, except the President, the Secretary, or a Vice President of The Ohio National Life Insurance Company can make or change any contract. Under penalty of perjury, each Owner certifies that his/her Social Security (or taxpayer identification) number is correct as it appears in this application.


form 4896 rev. 1/11		5

15.		State Insurance Fraud Notices For Arizona and Kansas Applicants: The undersigned proposed insured and agent represent that the Proposed Insured has read, or had read to him/her, the completed application and that he/she realizes that any false statement or misrepresentation therein may result in loss of coverage under the policy. It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Only a court of law can make a determination of guilt regarding insurance fraud.

		For Arkansas and Rhode Island Applicants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

		For DC Applicants: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

		For Kentucky Applicants: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud which is a crime. I have read and understood this notice.

		For Maine Applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

		For Missouri, West Virginia and Wisconsin Applicants: The undersigned Proposed Insured and Agent represent that the Proposed Insured has read, or had read to him/her, the completed application and that he/she realizes that any false statement or misrepresentation therein may result in loss of coverage under the policy.

		For New Mexico Applicants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

		For Ohio and Oklahoma Applicants: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

		For Tennessee Applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

16.		Annuitant Owner’s Signature(s)


Annuitant Signature		Date		Signed at (City/State)


Owner /Applicant Signature (If different from Annuitant)		Date		Signed at (City/State)

(If Trustee, sign with title and attach Trust Certification Form V-4603.) (If corporation, signature of office and title, attach a copy of Corporate Resolution.)


Joint Owner Signature		Date		Signed at (City/State)


		E-mail Address of Owner or of Annuitant if Contract issued to Custodian

17.		Statement of Agent

		Will this contract change or replace any existing life insurance policy or an annuity of this or any other company? o Yes o No

		If yes, explain in Special Requests, Section 13.

		I certify that I am authorized and qualified to discuss this contract. I certify that The Ohio National Life Insurance Company approved all sales material used in the solicitation of this application, copies of which were provided to the applicant. I also certify that I witnessed the Applicant’s signature.


Agent Full Name (Print)		Agent Signature		Agent’s License ID Number


Agent Phone Number	Broker/Dealer Name	Ohio National Agency Code

Rep. Option:	Client ID (For Linking):


form 4896 rev. 1/11		6