American Legacy III Plus The Lincoln National Life
Variable Annuity Application Insurance Company
Fort Xxxxx, Indiana
--------------------------------------------------------------------------------
Instructions: Please type or print. ANY ALTERATIONS TO THIS APPLICATION MUST BE
INITIALED BY THE CONTRACT OWNER.
--------------------------------------------------------------------------------
1a Rights Of Accumulation (If additional space is needed, use Section 12.)
[ ] I own an American Funds mutual fund or American Legacy variable
annuity, which may entitle me to increased bonus credit amounts as
described in the prospectus. My account numbers are:
------------------------------ ------------------------------
[ ] The registration of some of my shares differs. Their account numbers
are (may include spouse and/or children under 21):
Account no. Name SSN
------------------ ----------------------- -------------
Account no. Name SSN
------------------ ----------------------- -------------
-------------------------------------------------------------------------------
1b Contract Owner Note: Maximum age of Contract Owner is 85.
Social Security number/TIN [ ][ ][ ]-[ ][ ]-[ ][ ][ ][ ]
----------------------------------
Full legal name or trust name* Date of birth [ ][ ] [ ][ ] [ ][ ]
Month Day Year
[ ] Male [ ] Female
----------------------------------- Home telephone number [ ][ ][ ]-[ ][ ][ ]-[ ][ ][ ][ ]
Street address
Date of trust* [ ][ ] [ ][ ] [ ][ ]
---------------------------------- Month Day Year
City State ZIP
Is trust revocable?*
---------------------------------- [ ] Yes [ ] No
Trustee name*
*This information is required for trusts.
-------------------------------------------------------------------------------
1c Joint Contract Owner Note: Maximum age of Joint Contract Owner is 85.
Social Security number [ ][ ][ ]-[ ][ ]-[ ][ ][ ][ ]
---------------------------
Full legal name Date of birth [ ][ ] [ ][ ] [ ][ ]
Month Day Year
[ ] Male [ ] Female
[ ] Spouse [ ] Non-Spouse
-------------------------------------------------------------------------------
2a Annuitant Note: Maximum age of Annuitant is 85. (If no Annuitant is
specified, the Contract Owner, or Joint Owner if younger, will be the
Annuitant.)
Social Security number [ ][ ][ ]-[ ][ ]-[ ][ ][ ][ ]
----------------------------------
Full legal name Date of birth [ ][ ] [ ][ ] [ ][ ]
Month Day Year
[ ] Male [ ] Female
----------------------------------- Home telephone number [ ][ ][ ]-[ ][ ][ ]-[ ][ ][ ][ ]
Street address
----------------------------------
City State ZIP
-------------------------------------------------------------------------------
2b Contingent Annuitant Note: Maximum age of Contingent Annuitant is 85.
--------------------------------- Social Security number [ ][ ][ ]-[ ][ ]-[ ][ ][ ][ ]
Full legal name
-------------------------------------------------------------------------------
3 Beneficiary(ies) of Contract Owner (List additional beneficiaries on a
separate sheet. If listing children, use full legal names.)
%
---------------------------------------- ------------------------------ ------------- ----
Full legal name or trust name* Relationship to Contract Owner SSN/TIN
[ ] Primary [ ] Contingent
%
---------------------------------------- ------------------------------ ------------- ----
Full legal name or trust name* Relationship to Contract Owner SSN/TIN
[ ] Primary [ ] Contingent
%
---------------------------------------- ------------------------------ ------------- ----
Full legal name or trust name* Relationship to Contract Owner SSN/TIN
[ ] Primary [ ] Contingent
Date of trust* [ ][ ] [ ][ ] [ ][ ] Is trust revocable?*
---------------------------------------- Month Day Year [ ] Yes [ ] No
Executor/Trustee name* *This information is required for trusts.
To specify an annuity payment option for your beneficiary, please complete the
Beneficiary Payment Options form (29953).
-------------------------------------------------------------------------------
4 Type of American Legacy Contract
Nonqualified: [ ] Initial Contribution OR [ ] 1035 Exchange
Tax-Qualified (must complete plan type): Tax Year ______ Transfer OR
[ ] Rollover Plan Type (check one): [ ] Xxxx XXX [ ] Traditional IRA
[ ] Non-ERISA 403(b)* (transfers only)
*Indicate plan year-end: [ ][ ] [ ][ ]
Month Day
Page 1
5a Allocation (This section must be completed.)
Initial minimum: $25,000
Future contributions will follow the allocation below. If DCA option is
selected, the entire amount of each future contribution will follow the
allocation in Section 5b.
If no allocations are specified in Section 5a or 5b, the entire amount will be
allocated to the Cash Management Fund pending instructions from the Contract
Owner.
--------------------------------------------------------
Please allocate my contribution of:
$____________________ OR $ ___________________
Initial contribution Approximate amount
from previous carrier
--------------------------------------------------------
INTO THE FUND(S) BELOW
Use whole percentages
% Global Growth Fund
--------
% Global Small Capitalization Fund
--------
% Growth Fund
--------
% International Fund
--------
% New World Fund
--------
% Growth-Income Fund
--------
% Asset Allocation Fund
--------
% High-Yield Bond Fund
--------
% Bond Fund
--------
% U.S. Govt./AAA-Rated Securities Fund
--------
% Cash Management Fund
--------
% Fixed Account
--------
% DCA Fixed Account (must complete 5b)
--------
% Total (must = 100%)
========
--------------------------------------------------------
5b Dollar Cost Averaging (Complete only if electing DCA.)
$1,500 minimum required in the Holding Account
----------------------------------------------------------------------
Total amount to DCA: $
--------------------
OR
MONTHLY amount to DCA: $
--------------------
----------------------------------------------------------------------
OVER THE FOLLOWING PERIOD: ---------------------
MONTHS (6-60)
----------------------------------------------------------------------
FROM THE FOLLOWING HOLDING ACCOUNT (check one):
DCA Fixed Account
-----
Cash Management Fund*
-----
U.S. Govt./AAA-Rated Securities Fund*
-----
----------------------------------------------------------------------
INTO THE FUND(S) BELOW
Use whole percentages *The holding account and
the DCA fund elected
cannot be the same.
% Global Growth Fund
--------
% Global Small Capitalization Fund
--------
% Growth Fund
--------
% International Fund
--------
% New World Fund
--------
% Growth-Income Fund
--------
% Asset Allocation Fund
--------
% High-Yield Bond Fund
--------
% Bond Fund
--------
% U.S. Govt./AAA-Rated Securities Fund*
--------
% Cash Management Fund*
--------
% Fixed Account
--------
% Total (must = 100%)
========
----------------------------------------------------------------------
Future contributions will not automatically start a new DCA program.
Instructions must accompany each DCA contribution.
--------------------------------------------------------------------------------
5c Cross-Reinvestment or Portfolio Rebalancing
To elect either of these options, please complete the Cross-Reinvestment form
(28051) or the Portfolio Rebalancing form (28887).
--------------------------------------------------------------------------------
6 Automatic Withdrawals
Note: Withdrawals exceeding 10% of the greater of total contract value or
premium payments per contract year may be subject to contingent deferred sales
charges.
[ ] Please provide me with automatic withdrawals
based on _____% (may be between 1-10%) of the
greater of total contract value or
premium payments, payable as follows:
[ ] Monthly [ ] Quarterly [ ] Semiannually [ ] Annually
Begin withdrawals in [ ] [ ] [ ] [ ]
Month Year
OR
[ ] Please provide me with
automatic withdrawals
of $____________
[ ] Monthly ______ Quarterly ______ Semiannually ______ Annually
Begin withdrawals in _____ ______
Month Year
ELECT ONE: [ ] Do withhold taxes Amount to be withheld $_______ or _______%
[ ] Do not withhold taxes
ELECT ONE: [ ] Send check to address of record
[ ] Direct deposit
For direct deposit into your bank account, the Electronic Fund
Transfer Authorization form (27326) must be completed and
submitted with a voided check or a savings deposit slip.
OR
[ ] Send check to the
following alternate
address:
---------------------------------
---------------------------------
---------------------------------
Page 2
--------------------------------------------------------------------------------
7 Automatic Bank Draft
------------------------------------------------------------------------------
Print account holder name(s) EXACTLY as shown on bank records
ATTACH VOIDED CHECK
-----------------------------------------------------------
Bank name ABA number
------------------------------------------------------------------------------
Bank street address City State ZIP
Automatic bank draft start date:
[_][_] [_][_] [_][_] $
Month Day (1-28) Year ------------------------------ ---------------
Checking account number Monthly amount
I/We hereby request and authorize you to pay and charge to my/our account
checks or electronic fund transfer debits processed by and payable to the
order of Lincoln Life, P.O. Box 2348, Fort Xxxxx, IN 46801-2348, provided
there are sufficient collected funds in said account to pay the same upon
presentation. It will not be necessary for any officer or employee of Lincoln
Life to sign such checks. I/We agree that your rights in respect to each such
check shall be the same as if it were a check drawn on you and signed
personally by me/us. This authority is to remain in effect until revoked by
me/us, and until you actually receive such notice I/we agree that you shall be
fully protected in honoring any such check or electronic fund transfer debit.
I/We further agree that if any such check or electronic fund transfer debit be
dishonored, whether with or without cause and whether intentionally or
inadvertently, you shall be under no liability whatsoever even though such
dishonor results in the forfeiture of insurance or investment loss to me/us.
--------------------------------------------------------------------------------
8 Telephone/Internet Authorization (Check box if this option is desired.)
[_] I/We hereby authorize and direct Lincoln Life to accept instructions via
telephone or the internet from any person who can furnish proper
identification to exchange units from subaccount to subaccount, change the
allocation of future investments, and/or clarify any unclear or missing
administrative information contained on this application at the time of issue.
I/We agree to hold harmless and indemnify Lincoln Life, American Funds
Distributors, Inc. and their affiliates and any mutual fund managed by such
affiliates and their directors, trustees, officers, employees and agents for
any losses arising from such instructions.
--------------------------------------------------------------------------------
9 Replacement Will the proposed contract replace any existing annuity or life
insurance contract?
ELECT ONE: [_] No [_] Yes If yes, complete the attached 1035 Exchange or
Qualified Retirement Account Transfer form.
(Attach a state replacement form if required by the state in which the
application is signed.)
------------------------------------------------------------------------------
Company name
------------------------------------------------------------------------------
Plan name Year issued
--------------------------------------------------------------------------------
Fraud Warning Residents of all states except Virginia and Washington, please
note:
Any person who knowingly, and with intent to defraud any insurance company or
other person, files or submits an application or statement of claim containing
any materially false or deceptive 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.
--------------------------------------------------------------------------------
10 Signatures
All statements made in this application are true to the best of my/our
knowledge and belief, and I/we agree to all terms and conditions as shown.
I/We acknowledge receipt of current prospectuses for American Legacy III Plus
and American Funds Insurance Series/TM/ and verify my/our understanding that
all payments and values provided by the contract, when based on investment
experience of the funds in the Series, are variable and not guaranteed as to
dollar amount. Under penalty of perjury, the Contract Owner(s) certifies that
the Social Security (or taxpayer identification) number(s) is correct as it
appears in this application.
-------------------------------------------
Signed at (city) State Date [_][_] [_][_] [_][_]
Month Day Year
-------------------------------------------
Signature of Joint Contract Owner
Contract Owner (if applicable)
-------------------------------------------
Signed at (city) State Date [_][_] [_][_] [_][_]
Month Day Year
-------------------------------------------
Signature of Annuitant (Annuitant must sign
if Contract Owner is a trust or custodian.)
================================================================================
FINANCIAL ADVISER MUST COMPLETE REVERSE SIDE (PAGE 4)
================================================================================
Page 3
================================================================================
THE FOLLOWING SECTIONS MUST BE COMPLETED BY THE SECURITIES DEALER OR FINANCIAL
ADVISER. Please type or print.
================================================================================
11 Insurance in Force Will the proposed contract replace any existing annuity
or life insurance contract?
ELECT ONE: [_] No [_] Yes If yes, please list the insurance in force on
the life of the proposed Contract Owner(s) and Annuitant(s):
(Attach a state replacement form if required by the state in which the
application was signed.)
$
--------------------------------------------------------------------------------
Company name Year issued Amount
--------------------------------------------------------------------------------
12 Additional Remarks
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
13 American Funds/American Legacy Total Account Value (For rights of
accumulation purposes.)
My client owns a total of $ ____________________ in the American Funds
mutual funds and/or American Legacy variable annuity products. NOTE: Please
include the deposit amount for the purchase of this contract.
--------------------------------------------------------------------------------
14 Dealer Information Note: Licensing appointment with Lincoln Life is
___1 ___2 ___3 required for this application to be processed.
If more than one representative, please indicate
names and percentages in Section 12.
------------------------------------------ [_][_][_] [_][_][_]-[_][_][_][_]
Registered representative's name Registered representative's
(print as it appears on NASD licensing) telephone number
------------------------------------------ [_][_][_]-[_][_]-[_][_][_][_]
Client account number at dealer Registered representative's SSN
(if applicable)
----------------------------------------------------------------------------
Dealer's name
----------------------------------------------------------------------------
Branch address City State ZIP
[_] CHECK IF BROKER CHANGE OF ADDRESS
--------------------------------------------------------------------------------
15 Representative's Signature
The representative hereby certifies that he/she witnessed the signature(s)
in Section 10 and that all information contained in this application is true
to the best of his/her knowledge and belief.
----------------------------------------------------------------------------
Signature
--------------------------------------------------------------------------------
Send completed application -- with a check made payable to
Lincoln Life -- to your investment dealer's home office
or to:
Lincoln Life
P.O. Box 2348
Fort Xxxxx, IN 46801-2348
By Express Mail: Lincoln Life
Attention: American Legacy Operations
0000 Xxxxx Xxxxxxx Xxxxxx
Xxxx Xxxxx, XX 00000
If you have any questions regarding this application, please call Lincoln Life
at 000 000-0000.
Page 4
