Exhibit 5
[Xxxxxxx & Xxxx Advisors Select Income AnnuitySM]
Individual Single Purchase Payment Immediate
Variable and/or Fixed Income Annuity Application
$35,000 Minimum Purchase Payment
Nationwide Life Insurance Company
P.O. Box 182449
Columbus, Ohio 43218-2449
CONTRACT TYPE This Contract is established as a: A Contract type must be
selected
NON-QUALIFIED XXX Xxxx XXX 403(b) (non-ERISA only)
CONTRACT OWNER JOINT OWNER Spouse only except in
HI, PA and VT.
Last Name or Trust Name Last Name
First Name or Trust Name (continued) MI First Name MI
Address Address
Telephone No. ( ) H W
Sex M F Birthdate / / Sex M F Birthdate / /
MM DD YYYY MM DD YYYY
(Maximum issue age through age 85) (Maximum issue age through age 85)
Soc. Sec. No. or Tax ID Soc. Sec. No. or Tax ID
ANNUITANT Complete only if JOINT ANNUITANT Complete only if
different from Contract Income Option allows payments to a
Owner survivor. Spouse only for IRAs.
Last Name Last Name
First Name MI First Name MI
Address Address
Telephone No. ( ) H W
Sex M F Birthdate / / Sex M F Birthdate / /
MM DD YYYY MM DD YYYY
(Maximum issue age through age 85) (Maximum issue age through age 85)
Soc. Sec. No. or Tax ID Soc. Sec. No. or Tax ID
BENEFICIARY Whole percentages only, all primary beneficiaries must total
100%; all contingent beneficiaries must total 100%.
Relationship Birthdate
Primary Contingent Print Full Name (Last, First, MI)
Relationship Birthdate
Allocation to Annuitant Soc. Sec. No. (MM/DD/YY)
%
%
%
%
PURCHASE PAYMENT Rollover Payment Enclosed Transfer/1035
(requires transfer form)
Purchase Payment $ submitted (minimum $35,000). A copy of
this application properly signed by the registered representative will
constitute receipt for such amount. If this application is declined by
the Company, there will be no liability on the part of the Company, and
any payments submitted with this application will be refunded.
INCOME START DATE (Payments are typically received
within seven to ten days following the Income Start
Date.)
FREQUENCY OF Monthly Quarterly Semi-Annually Annually
PAYMENTS
Electronic Funds Transfer (If Electronic Funds Transfer is not selected,
a check will be issued and mailed to you.)
Bank Name and Address Bank Telephone Number ( )
Type of Account (Please attach
voided check or deposit slip)
Checking Savings
Bank Routing No. Bank Account No.
INCOME OPTIONS CANNOT BE CHANGED ONCE ELECTED
(only one option may be selected)
SINGLE LIFE WITH TERM CERTAIN YEARS* Select 10 years 15 years or 20
years
SINGLE LIFE CASH REFUND*
SINGLE LIFE*
JOINT AND % LAST SURVIVOR** Select 50% 75% or 100%
JOINT AND 100 % LAST SURVIVOR WITH TERM CERTAIN YEARS** Select 10 years
15 years or 20 years
JOINT AND 100% SURVIVOR WITH CASH REFUND**
JOINT AND 50% SURVIVOR**
TERM CERTAIN YEARS (Between 5 and 30 years)
*Birth Certificate of Annuitant Required **Birth Certificate of Both
Annuitant and Joint Annuitant Required
REMARKS
PURCHASE PAYMENT ALLOCATION Whole percentages only, must total 100%. A
Contract cannot be issued unless this
section is complete.
The underlying investment options listed on this application are only
available in variable annuity insurance products issued by life insurance
companies or, in some cases, through participation in certain qualified
pension or retirement plans. They are NOT offered to the general public
directly.
W & R TARGET FUNDS, INC. % FIXED PAYMENT
ALLOCATION
% Asset Strategy
Portfolio
% Balanced
Portfolio
% Bond Portfolio
% Growth Portfolio
% High Income
Portfolio
% Core Equity
Portfolio
% International
Portfolio
% Limited-Term
Bond Portfolio
% Money Market
Portfolio
% Science and
Technology
Portfolio
% Small Cap
Portfolio
% Value Portfolio
For your variable investment options, please select the following:
ASSUMED INVESTMENT RETURN 3.5% 5.0% 6.0%
ANNUAL BENEFIT LEVELING FOR VARIABLE ANNUITY PAYMENTS* YES NO
*If this option is elected, Annual Frequency of Payments cannot be chosen.
NOTICE TO AZ RESIDENTS ONLY:
Upon written request, the Company agrees to provide, within a reasonable
time, reasonable factual information regarding the benefits and provisions
of the annuity Contract to the Contract Owner. If for any reason the
Contract Owner is not satisfied with the Contract, the Contract may be
returned within ten days after it is delivered and the Contract Value will
be refunded in full. For IRAs, if the Contract Owner returns the Contract
within the ten-day period, the Company will return the Purchase Payment.
NOTICE TO MN RESIDENTS ONLY:
This Contract is not protected by the Minnesota Life and Health Insurance
Guaranty Association or the Minnesota Insurance Guaranty Association. In
the case of insolvency, payment of claims is not guaranteed. Only the
assets of the Insurer will be available to pay your claim.
NOTICE TO MN, ND, SC, SD AND VT RESIDENTS ONLY:
Annuity payments, death benefits, surrender values, and other Contract
values provided by this Contract, when based on the investment experience
of a separate account are variable and may increase or decrease in
accordance with the fluctuations in the net investment factor, as
applicable, and are not guaranteed as to fixed-dollar amount, unless
otherwise specified.
Additionally, 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.
NOTICE TO AR, CO, KY, LA, ME, NM, OH AND TN RESIDENTS ONLY:
Any 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.
NOTICE TO DC RESIDENTS ONLY:
WARNING: 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.
NOTICE TO WA RESIDENTS ONLY:
Any 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 PA RESIDENTS ONLY:
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.
CONTRACT OWNER SIGNATURES
To the best of my knowledge and belief, I represent my answers to the
questions below to be accurate and complete. I acknowledge that I have
received and understand the current prospectus for this annuity Contract.
Are you a U.S. Citizen? Yes No
If No,country of citizenship
Yes No Will the applied for Contract replace existing annuities or
insurance?
Please send me a copy of the Statement of Additional Information to the
Prospectus.
I consent to having the Company send my prospectus(es), confirmation
statements, quarterly statements, annual statements, and other product
information to my e-mail address shown below.
CONTRACT OWNERS E-MAIL ADDRESS
STATE IN WHICH APPLICATION WAS SIGNED DATE
To authorize the Company to allow the exercise of ownership rights
independently by EITHER the Contract Owner or Joint Owner, both owners
please initial here: (Contract Owner) _________, (Joint Owner) __________.
The contract payments or values under the variable annuity provisions of
the Contract are variable and are not guaranteed as to fixed dollar
amount.
CONTRACT OWNER
Signature
JOINT OWNER
Signature
REGISTERED REPRESENTATIVE INFORMATION
Yes No Do you have any reason to believe the Contract applied for is
to replace existing annuities or insurance?
REGISTERED REPRESENTATIVE SIGNATURE
Signature
NAME (Please Print)
REGISTERED REPRESENTATIVE SSN
FIRM NAME PHONE ( )
ADDRESS
FEDERAL INCOME TAX
WITHHOLDING
A. I elect to have no income tax withheld from my income payments (do
not complete B or C)
B. I want my withholding from each income payment to be figured using
the number of allowances and marital status shown (you may also
designate an additional amount in item C)
Allowances Single Married Married, but withhold at higher single rate
C. Withhold the following additional amount from each income payment (you
must complete B) $
