American Legacy III C Share The Lincoln National Life
Variable Annuity Application Insurance Company
Fort Xxxxx, Indiana
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Instructions: Please type or print. ANY ALTERATIONS TO THIS APPLICATION MUST BE INITIALED BY THE CONTRACT OWNER.
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1a Contract Owner Social Security number/TIN _______-_____-______
Full legal name or trust name*______________________________ Date of birth ____-____-_____ ___ Male __ Female
Month Day Year
Street address______________________________________________ Home telephone number _____ _____-_________
City_________________________ State________ ZIP_____________ Date of trust ____-____-_____ Is trust revocable?* __ Yes __ No
Month Day Year
Trustee name* ______________________________________________
Note: Maximum age of Contract Owner is 90. *This information is required for trusts.
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1b Joint Contract Owner
Full legal name_____________________________________________ Social Security number _______- _____-________
Date of birth ____-____-_____ ___ Male ___ Female
Month Day Year
Note: Maximum age of Joint Contract Owner is 90. ___ Spouse ___ Non-Spouse
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2a Annuitant (If no Annuitant is specified, the Contract Owner, or Joint Owner if younger, will be the Annuitant.)
Full legal name ____________________________________________ Social Security number _______- _____-________
Street address _____________________________________________ Date of birth ____-____-_____ ___ Male __ Female
Month Day Year
City_________________________ State________ ZIP_____________ Home telephone number _____ _____-_________
Note: Maximum age of Annuitant is 90.
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2b Contingent Annuitant
Full legal name_____________________________________________ Social Security number _______- _____-________
Note: Maximum age of Contingent Annuitant is 90.
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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* ___ Primary ___ Contingent Relationship to Contract Owner SSN/TIN
____________________________________________________________ _______________________________ ________________ __________%
Full legal name or trust name* ___ Primary ___ Contingent Relationship to Contract Owner SSN/TIN
____________________________________________________________ _______________________________ ________________ __________%
Full legal name or trust name* ___ Primary ___ Contingent Relationship to Contract Owner SSN/TIN
____________________________________________________________ Date of trust* ____-____-_____ Is trust revocable?*
Executor/Trustee name* Month Day Year __ Yes __ No
*This information is required for trusts.
To specify an annuity payment option for your beneficiary, please complete the Beneficiary Payment Options form (29953).
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4 Type of American Legacy Contract
Nonqualified: ___ Initial Contribution OR ___ 1035 Exchange
Tax-Qualified (must complete plan type): ___ Transfer OR ___ Rollover
Plan Type (check one): ___ Xxxx XXX ___ Traditional IRA ___ l Non-ERISA 403(b)* (transfers only) *Indicate plan year-end: _____ ____
Month Day
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5a Allocation (This section must be completed.) 5b Dollar Cost Averaging (Complete only if electing DCA.)
Initial minimum: $25,000 $1,500 minimum required in the Holding Account
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Future contributions will follow the allocation below. If Total amount to DCA: $ _______________
DCA option is selected, the entire amount of each future OR
contribution will follow the allocation in Section 5b. MONTHLY amount to DCA: $ _______________
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. OVER THE FOLLOWING PERIOD: _______________
--------------------------------------------------------------- MONTHS (6-60)
Please allocate my contribution of:
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--------------------------------------------------------------- FROM THE FOLLOWING HOLDING ACCOUNT (check one):
$____________________ OR $_____________________ _____ DCA Fixed Account
Initial contribution Approximate amount _____ Cash Management Fund*
from previous carrier _____ U.S. Govt./AAA-Rated Securities Fund*
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INTO THE FUND(S) BELOW INTO THE FUND(S) BELOW
Use whole percentages Use whole percentages *The DCA Holding Account
and the DCA fund elected
_______________% Global Growth Fund _____________% Global Growth Fund cannot be the same.
_______________% Global Small Capitalization Fund _____________% Global Small Capitalization Fund
_______________% Growth Fund _____________% Growth Fund
_______________% International Fund _____________% International Fund
_______________% New World Fund _____________% New World Fund
_______________% Growth-Income Fund _____________% Growth-Income Fund
_______________% Asset Allocation Fund _____________% Asset Allocation Fund
_______________% High-Yield Bond Fund _____________% High-Yield Bond Fund
_______________% Bond Fund _____________% Bond Fund
_______________% U.S. Govt./AAA-Rated Securities Fund _____________% U.S. Govt./AAA-Rated Securities Fund*
_______________% Cash Management Fund _____________% Cash Management Fund*
_______________% DCA Fixed Account (must complete 5b) _____________% Total (must = 100%)
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_______________% Total (must = 100%) Future contributions will not automatically start a new
------------------------------------------------------------------ DCA program. Instructions must accompany each DCA
contribution.
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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).
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6 Automatic Withdrawals
_____ Please provide me with automatic withdrawals totaling _______ % of total contract value or $ __________________ (minimum: $50
per distribution/$300 annually) payable as follows:
_____ 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 OR ______ Send check to the following alternate address:
______ 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.
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7 Automatic Bank Draft
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Print account holder name(s) EXACTLY as shown on bank records
ATTACH VOIDED CHECK
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Bank name ABA number
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Bank street address City State ZIP
Automatic bank draft start date: $
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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.0. 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.
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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.
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9 Replacement Will the proposed contract replace any existing annuity or life insurance contract?
ELECT ONE: No Yes If yes, complete the 1035 Exchange or Qualified Retirement Account Transfer form.
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(Attach a state replacement form if required by the state in which the application is signed.)
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Company name
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Plan name Year issued
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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.
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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 C Share and American Funds Insurance
Series(SM) 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.
Date
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Signed at (city) State Month Day Year
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Signature of Contract Owner Joint-Contract Owner (if applicable)
Date
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Signed at (city) State Month Day Year
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Signature of Annuitant (Annuitant must sign if Contract Owner is a trust or custodian.)
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FINANCIAL ADVISER MUST COMPLETE REVERSE SIDE (PAGE 4)
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THE FOLLOWING SECTIONS MUST BE COMPLETED BY THE FINANCIAL ADVISER OR
SECURITIES DEALER. Please type or print.
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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.)
$
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Company name Year issued Amount
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12 Additional Remarks
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13 Dealer Information Note: Licensing appointment with Lincoln Life is required for this application to be processed. If more
than one representative, please indicate names and percentages in Section 12.
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Registered representative's name (print as it appears on NASD licensing) Registered representative's telephone number
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Client account number at dealer (if applicable) Registered representative's SSN
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Dealer's name
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Branch address City State ZIP
___ CHECK IF BROKER CHANGE OF ADDRESS
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14 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.
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Signature
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Send completed application - with a check made payable to Lincoln Life - to your investment
dealer's home office or to:
Lincoln Life By Express Mail. Lincoln Life
P.O. Box 2348 Attention: American Legacy Operations
Fort Xxxxx, IN 46801-2348 0000 Xxxxx Xxxxxxx Xxxxxx
Xxxx Xxxxx, XX 00000
If you have any questions regarding this application, please call Lincoln Life at 000 000-0000.
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