Ex-99.1.(5)(a)(4)

[Lincoln National Part II Application The Lincoln National Life Insurance Company
Life Insurace Co. for Life Insurance Administrator Mailing Address:
Logo] Corporate Specialty Markets 350 Church St., Hartford, CT 06103-1106

Section 1: Insured Information
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Proposed Insured (First, Middle Initial, Last) Place of Birth

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Date of Birth Social Security Sex (Circle) Current
(Mo-Day-Yr) Number
/ / - - M F Height __ft __in Weight ______lb.
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Residence Address (No., Street) PO Box City, State, ZIP

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Name of Beneficiary and Relationship: (Complete only if Owner is other than
Employer)

Primary
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Secondary
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If you answer NO to question 1, or YES to questions 3-7, explain Yes No
in the space provided.

1. Have you been actively at work daily on a full-time basis
(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.) |_| |_|
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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 2: Medical & Related Information
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3. Have you within the past 2 years: If "Yes", complete the Yes No
Aviation and/or Avocation questionnaire.
a. Flown or plan to fly as a pilot, student pilot or crew
member or intend to do so? |_| |_|

b. Engaged in scuba diving, vehicle racing, parachute
jumping or any form of motorcycling, or any other
hazardous sport or hobby? |_| |_|
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4. Within the last five years have you ever used:
a. Hallucinogenic or narcotic drugs not prescribed by a
doctor? |_| |_|
b. Alcoholic beverages? If yes, give amount and frequency. |_| |_|
c. Had or been advised to have medical treatment or
counseling from a commonly recognized practitioner or
organization for alcohol or drug use? |_| |_|
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5. Have you, within the last 10 years:
a. Been diagnosed or treated for Acquired Immune
Deficiency Syndrome (AIDS), or AIDS-Related Complex
(ARC)? |_| |_|
b. Been diagnosed or treated for immune deficiency (other
than AIDS), anemia or other blood disorder (other than
for HIV)? |_| |_|
c. Had recurrent fever, fatigue or unexplained weight
loss? |_| |_|
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6. Other than the above, have you ever been diagnosed or
treated for:
a. Chest pain, high blood pressure, stroke, or disease of
the heart, blood vessels, or lungs; |_| |_|
b. Diabetes, mental or emotional disorder; disease of the
brain or nervous system, convulsions; |_| |_|
c. Cancer; tumor; disease of the stomach, intestines,
liver or kidneys? |_| |_|
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7. Have you in the last five years, had a checkup,
consultation, illness, injury, or diagnostic test or been
advised to have any diagnostic test, hospitalization or
surgery by any licensed physician, practitioner or health
facility? |_| |_|
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Explanations
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Number, nature and severity of condition, frequency of attacks, treatments
received, medication, dates, name, address & phone number of medical attendants
and hospitals
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Ques. Details
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Name & Address of physician last seen

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Date last seen

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Name & Address of primary care physician

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Date and reason last consulted

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The signatures below represent the following:

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 in this application material to the risk are still true and
complete when the policy is delivered and the entire first premium is paid.

I agree to advise the Company or producer in writing of any known or suspected
changes in the health of the proposed insured, or of any changes to any answers
on this application, prior to delivery of this policy.

AUTHORIZATION TO RELEASE INFORMATION

TO: any licensed physician, medical practitioner, hospital, clinic or medically
related facility, insurance company, consumer reporting agency, MIB, Inc. and
the insurance producer through whom application is being made.

On behalf of myself, I authorize you to release to Lincoln Life, or its
representatives, for purposes of determining eligibility for life or health
insurance coverage or claims for benefits:

any information or records concerning the mental and physical history,
condition and treatment, general character, habits, reputation, mode of
living, occupation, income, financial status, aviation activities and
hazardous hobbies of any person to be insured. This authorization is valid
until 2 years after the effective date of any contract issued in connection
with this authorization.

I authorize Lincoln Life to obtain an investigative consumer report. These
reports usually include an interview with the person to be insured. However I
understand that I am entitled to be interviewed by any consumer reporting
agency which may be asked to prepare such a report as long as I can reasonably
be contacted during normal business hours.

I have received Lincoln Life's Underwriting Notice, which includes the MIB,
Inc., and Fair Credit Reporting Act Notices. I understand that information
pertaining to me will not be disclosed without my authorization except as
described under "Disclosure of Information to Others" in the accompanying
Underwriting Notice, or as otherwise permitted or required by law.

I understand that the information released under this authorization will be
used for purposes of determining eligibility for life or claims for benefits,
and I authorize Lincoln Life to redisclose the information for those purposes
to MIB, Inc., to any reinsurer, and to other life insurance companies with whom
I have or may apply for coverage or to whom a claim for benefits may be
submitted.

A photocopy of this authorization shall be as valid as the original. I
understand that upon request I may receive a copy of this authorization.

Signed at (City & State) ____________________________ on (Date) _____________

Signature:___________________________________________

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