Ex-99.1.(5)(a)(3)
[Lincoln National Part I Application for The Lincoln National Life Insurance Company
Life Insurace Co. Lincoln Life Insurance Administrator Mailing Address:
Logo] Corporate Specialty Markets 350 Church St., Hartford, CT 06103-1106
Section 1 Employer Information
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Company Name Taxpayer Identification Number
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Address
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Plan Administration Contact (Send all correspondence to named contact)
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Name Telephone Number
( )
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Address
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Owner Designation (Select One)
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|_| Company |_| Insured |_| Trust (Name of Trust, Trustee and Date of Trust)
|_| Other
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Owner Name
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Address
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Beneficiary Designation (Select One)
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|_| Corporation
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|_| Individual (Name and Relationship)
Primary _______________________________________________________________
Contingent______________________________________________________________
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|_| Trust
Name of Trust___________________________________________________________
Trustee Name_______________________________ Date of Trust ______________
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|_| Split Dollar (enclose a copy of split dollar agreement)
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|_| Other
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Policy Information
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State of Delivery
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Basic Plan Death Benefit Option Term Rider
Percentage
|_| Corporate Universal Life ________________%
|_| Corporate Variable Universal Life |_| 1 |_| 2 |_| 3
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Planned Premium Funding Schedule
|_| Guideline Premium Test |_| Years |_| Age
|_| Cash Value Accumulation Test Number of Years ____ Pay to Age ___
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Plan Effective Date Billing Frequency
|_| Annual |_| Semi-Annual |_| Quarterly |_| Monthly
|_| Single Premium
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Coverage Information: (Select one)
Specified Amount $ _______________ |_| See attached Census
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Amount of life insurance presently in force or applied for:
(Lincoln Life) $_________________ (Other Companies Total) $_________________
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Will life insurance or annuity in any company be replaced or changed if
insurance applied for is issued?
|_| Yes |_| No
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Section 2
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Employee Name Social Security Number Sex
- - |_| M |_| F
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Address Date of Birth (Mo-Day-Yr)
-----/------/------
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Occupation Title Hire Date (Mo-Day-Yr)
------/------/------
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1. Have you been actively at work daily on a full-time basis Yes No
(35 hours/week) performing all duties of your regular
occupation, at customary place of employment for the past 3
months? (Disregard vacation days, normal non-working days
and absences that total less than 4 consecutive days.) |_| |_|
If you answer NO to question 1, Complete Part II Application
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2. Have you used any tobacco products in the past 12 months? If
yes, how much and date last used:
|_| Cigarettes ________ |_|Cigars ________ |_| Pipe ________
|_| Smokeless tobacco ________ |_| |_|
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Section 3 (Must be completed by Owner)
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Owner Taxpayer Identification Number
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|_| Individual Taxpayer Identification Number |_| Partnership |_| Corporation
|_| Trustee |_| Other
|_||_|-|_||_|-|_||_||_||_| |_||_|-|_||_||_||_||_||_||_|
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Certification --- Under penalties of perjury, I certify that:
(1) The number shown above is my correct Taxpayer Identification Number (or am
waiting for a number to be issued to me), and
(2) I am not subject to backup withholding because: (a) I am exempt from backup
withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a
failure to report all interest or dividends, or (c) the IRS notified me
that I am no longer subject to backup withholding (does not apply to real
estate transactions, mortgage interest paid, the acquisition or abandonment
of secured property, contributions to an Individual Retirement Arrangement
(IRA), and payments other than interest and dividends).
CERTIFICATION INSTRUCTIONS. --- You must cross out item (2) above if you have
been notified by the IRS that you are currently subject to backup withholding
because of underreporting interest or dividends on your tax return.
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Any person who, knowingly presents a false or fraudulent claim for payments of
a loss or benefit or knowingly presents false information in an application for
insurance may be guilty of a crime and may be subject to fines and confinement
in prison.
The answers above are true and complete to the best of my knowledge and belief.
I agree that coverage can take effect only if the proposed insured is alive,
and all answers material to the risk are still true and complete when the
policy is delivered and the entire first premium is paid for. I agree that no
agent may alter the terms of the application or the policy. No agent may waive
any of Lincoln Life's rights or requirements.
If this is a request to exercise an option in an existing policy, the request
will become effective in accordance with the terms of that option. If this is a
request for change, any and all values may be used to pay for the change and to
repay any loan indebtedness. The changed policy will be subject to any loan
indebtedness not repaid. Any assignment in effect at the time of this request
will apply to any new insurance issued.
Signature of (Proposed) Insured _______________________________ Date __________
Signature of Owner ____________________________________________ Date __________
Signature of Agent ____________________________________________ Date __________
Signed at (City and State) ____________________________________
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List Individuals authorized to sign for the Corporation
Print Name___________________________ Print Name_____________________________
Title________________________________ Title__________________________________
Signature____________________________ Signature______________________________
Print Name___________________________ Print Name_____________________________
Title________________________________ Title__________________________________
Signature____________________________ Signature______________________________
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