APPLICATION FOR GROUP ANNUITY CONTRACT MADE TO NATIONWIDE LIFE INSURANCE COMPANY (The Company) ONE NATIONWIDE PLAZA COLUMBUS, OHIO 43216

Transcription

1 PPLICTION FOR GROUP NNUITY CONTRCT MDE TO NTIONWIDE LIFE INSURNCE COMPNY (The Company) ONE NTIONWIDE PLZ COLUMBUS, OHIO TRUSTEE(S) OF THE (Exact Name of applicant, e.g., BC Company, Inc. or Trustees of XYZ Company, Inc. Retirement Trust) TRUST The applicant applies for the attached Group nnuity Contract. The applicant approves and accepts the terms of the Contract. The applicant certifies that to the best of its knowledge- 1. The applicant has the authority to enter into the Contract. 2. The applicant's plan qualifies under Section 401 of the Internal Revenue Code. If not so qualified, describe type of plan-. 3. The applicant, if a sole proprietorship or partnership or if a trustee representing a Plan established or maintained by a sole proprietorship or partnershipa. is or represents a Plan established or maintained by a financially sophisticated law, accounting, investment banking, pension consulting, or investment advisory firm with financial/business knowledge and experience, capable of adequately representing its interests and those of its employees; or b. has obtained the advice of an independent, expert financial or business advisor having no affiliation or material business relationship with The Company, and capable of adequately representing the interest of the applicant and its employees. c. the Plan covers only (i) the employees of an employee benefit plan established or maintained by a single employer or employers under common control or (ii) the employees of any employer which contributes to a plan established or maintained by an employee organization or (iii) the employees of any employer which contributes to a plan maintained by more than one employer which is not established by an employee organization. 4. This Contract is a permissible investment under the applicant's plan. If The Company fails to accept this pplication, the amount of deposit will be refunded without interest. LL CONTRCT VLUES BSED ON THE INVESTMENT RESULTS OF VRIBLE FUND RE VRIBLE (MY INCRESE OR DECRESE) ND RE NOT GURNTEED S TO DOLLR MOUNT. NOTICE TO LL RESIDENTS OF FL, MN, ND, P, SC, SD, TX, VT nnuity payments, death benefits, surrender values, and other Contract values provided by this Contract, when based on the investment experience of a separate account, or when subject to a Market Value djustment are variable, may increase or decrease in accordance with the fluctuations in the net investment factor or application of a Market Value djustment, as applicable, and are not guaranteed as to fixed-dollar amount, unless otherwise specified. Market Value djustment may be assessed on any Guaranteed Term Options that have not matured just prior to nnuitization and would be in addition to the scheduled surrender penalty charge. dditionally, any benefits, values or payments based on performance of the underlying investment options may vary and are NOT guaranteed by Nationwide Life Insurance Company, any other insurance company, by the U.S. Government, or any State Government. They are NOT federally insured by the FDIC, the Federal Reserve Board or any agency Federal or State. FOR MN RESIDENTS ONLY This Policy or Contract is not protected by the Minnesota Life and Health Insurance Guaranty ssociation or the Minnesota Insurance Guaranty ssociation. In the case of insolvency, payment of claims is not guaranteed. Only the assets of the Insurer will be available to pay your claim. PO

2 FOR DC RESIDENTS ONLY WRNING- IT IS CRIME TO PROVIDE FLSE OR MISLEDING INFORMTION TO N INSURER FOR THE PURPOSE OF DEFRUDING THE INSURER OR NY OTHER PERSON. PENLTIES INCLUDE IMPRISONMENT ND/OR FINES. IN DDITION, N INSURER MY DENY INSURNCE BENEFITS IF FLSE INFORMTION MTERILLY RELTED TO CLIM WS PROVIDED BY THE PPLICNT. FOR FL RESIDENTS ONLY ny 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. FOR NJ RESIDENTS ONLY ny person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. FOR W RESIDENTS ONLY ny person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of a criminal offense under state law. NOTICE TO LL RESIDENTS OF R, DC, KY, L, ME, NM, OH, P ny person who, knowingly and with intent to injure, defraud or deceive 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 may be a crime and may subject such person to criminal and civil penalties, fines, imprisonment, or a denial of insurance benefits. I hereby represent that I have selected the funds as described within this application. Signature of Licensed gent Printed Name of Licensed gent License No/Fl License ID No. Signature of Licensed gent Printed Name of Licensed gent License No/Fl License ID No. pplicant Signature Typed or Printed pplicant Name Date Title (Trustee, If pplicable) PO

3 The Contract shall include the following Funds of the Separate ccount. PRIMRY PLUS Public Funds berdeen U.S. Equity Fund - berdeen U.S. Equity Fund - lliancebernstein Discovery Value Fund - Class K lliancebernstein International Value Fund - Class K llianzgi NFJ Mid-Cap Value Fund - MCP Fund(R) - Class R3 merican Balanced Fund(R) - Class R3 merican Century Equity Growth Fund - merican Century Income & Growth Fund- merican Century Inflation-djusted Bond Fund merican Century International Growth Fund - Class merican Century International Value Fund - merican Century Large Company Value Fund - merican Century Real Estate Fund - merican Century Short-Term Government Fund merican Century Ultra(R) Fund - merican Century Value Fund - merican High-Income Trust(SM) - Class R3 merican Mutual Fund(R) - Class R3 Baron sset Fund Baron Small Cap Fund Calvert Income Fund - Capital Income Builder(R) Fund - Class R3 Capital World Bond Fund(R) - Class R3 Capital World Growth and Income Fund(SM) - Class R3 DWS RREEF Real Estate Securities Fund - Eagle Mid Cap Growth Fund - Eagle Mid Cap Stock Fund - Eaton Vance Floating-Rate Fund - EuroPacific Growth Fund(R) - Class R3 Federated Bond Fund- Class F Shares Federated High Yield Trust- Service Shares Federated Intermediate Corporate Bond Fund - Service Shares Federated Kaufmann Fund - Shares Fidelity dvisor Balanced Fund- Fidelity dvisor Equity Growth Fund- Fidelity dvisor Equity Income Fund- Fidelity dvisor Freedom 2005 Fund - Fidelity dvisor Freedom 2010 Fund - Fidelity dvisor Freedom 2015 Fund - Fidelity dvisor Freedom 2020 Fund - Fidelity dvisor Freedom 2025 Fund - Fidelity dvisor Freedom 2030 Fund - Fidelity dvisor Freedom 2035 Fund - Fidelity dvisor Freedom 2040 Fund - Fidelity dvisor Freedom 2045 Fund - Fidelity dvisor Freedom 2050 Fund - Fidelity dvisor Freedom 2055 Fund - Fidelity dvisor Growth Opportunities Fund- Fidelity dvisor Investment Grade Bond Fund - Class Fidelity dvisor Strategic Income Fund - Fidelity dvisor Value Strategies Fund - Fundamental Investors(SM) - Class R3 ClearBridge ggressive Growth Fund - Goldman Sachs Government Income Fund - ClearBridge Investors Large Cap Value Fund - Class Goldman Sachs Growth Opportunities Fund - Goldman Sachs Short Duration Government Fund - ClearBridge Large Cap Growth Fund - Columbia Diversified Equity Income Fund - Goldman Sachs Small Cap Value Fund - Columbia Equity Value Fund - Harbor International Fund - Investor Class Columbia High Yield Bond Fund - Intermediate Bond Fund of merica(r) - Class R3 Columbia Large Core Quantitative Fund - Invesco Comstock Fund - Davis New York Venture Fund, Inc. - Invesco Energy Fund - Investor Class Dreyfus ctive MidCap Fund - Invesco Equity and Income Fund- Dreyfus ppreciation Fund, Inc. Invesco Growth and Income Fund- Dreyfus International Value Fund - Invesco Mid Cap Core Equity Fund - DWS Equity Dividend Fund - Invesco Small Cap Equity Fund - PO

4 Janus Forty Fund - Class S JPMorgan Core Bond Fund - JPMorgan Mid Cap Growth Fund - Manning & Napier Fund, Inc. Pro-Blend Conservative Manning & Napier Fund, Inc. Pro-Blend Extended Manning & Napier Fund, Inc. Pro-Blend Maximum Manning & Napier Fund, Inc. Pro-Blend Moderate MFS Global High Yield Fund - MFS Research Bond Fund - MFS Value Fund - MFS(R) Total Return Fund- Nationwide Bond Index Fund- Nationwide Destination 2010 Fund - Nationwide Destination 2015 Fund - Nationwide Destination 2020 Fund - Nationwide Destination 2025 Fund - Nationwide Destination 2030 Fund - Nationwide Destination 2035 Fund - Nationwide Destination 2040 Fund - Nationwide Destination 2045 Fund - Nationwide Destination 2050 Fund - Nationwide International Index Fund- Nationwide Investor Destinations ggressive Fund- Nationwide Investor Destinations Conservative Fund- Nationwide Investor Destinations Moderate Fund - Nationwide Investor Destinations Moderately ggressive Fund- Nationwide Investor Destinations Moderately Conservative Fund- Nationwide Mid Cap Market Index Fund- Nationwide Money Market Fund - Institutional Class Nationwide Retirement Income Fund - Nationwide S&P 500 Index Fund- Nationwide Short Duration Bond Fund - Nationwide Small Cap Index Fund- Nationwide Variable Insurance Trust (NVIT) Multi- Manager Small Company Fund - Class I Neuberger Berman Mid Cap Intrinsic Value Fund New Perspective Fund(R) - Class R3 New World Fund(SM) - Class R3 Oppenheimer Capital ppreciation Fund- Oppenheimer Global Fund- Oppenheimer Global Opportunities Fund - Oppenheimer Global Strategic Income Fund- Oppenheimer International Bond Fund - Oppenheimer Limited-Term Government Fund - Oppenheimer Main Street Fund(R) Oppenheimer Main Street Small- & Mid-Cap Fund - PIMCO Low Duration Fund - PIMCO Real Return Fund - PIMCO Total Return Fund- Pioneer High Yield Fund - Pioneer Strategic Income Fund - PNC Multi-Factor Small Cap Value Fund - Russell Emerging Markets Fund - Russell Global Real Estate Securities Fund - Russell LifePoints Funds Strategy Fund - Russell LifePoints Funds Strategy Fund - Russell LifePoints Funds Strategy Fund - Russell LifePoints Funds - Balanced Strategy Fund - Russell LifePoints Funds - Conservative Strategy Fund - Russell LifePoints Funds - Equity Growth Strategy Fund - Russell LifePoints Funds - Growth Strategy Fund - Russell LifePoints Funds - Moderate Strategy Fund - Russell Short Duration Bond Fund - SmallCap World Fund(R) - Class R3 T. Rowe Price Growth Stock Fund - R Class The Bond Fund of merica(sm) - Class R3 The Growth Fund of merica(r) - Class R3 The Income Fund of merica(r) - Class R3 The Investment Company of merica(r) - R3 The New Economy Fund(R) - Class R3 Thornburg International Value Fund - Class I Thornburg Value Fund - Class I Class U.S. Government Securities Fund(SM) - Class R3 Victory Portfolios (The) - Diversified Stock Fund - Shares PO

5 PRIMRY Insurance Funds FUNDS RE NOT VILBLE T THIS TIME OPTIONL FUNDS RE NOT VILBLE T THIS TIME PO