[logo: Lincoln Life](TM) Part I Application for Lincoln Life &
Lincoln Life Insurance Annuity Company of New York
Corporate Specialty Markets Administrator Mailing Address:
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
[ ] 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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B10392 NY
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 (35 hours/week) Yes No
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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B10392 NY
[logo: Lincoln Life](TM) Part II Application for Lincoln Life &
Lincoln Life Insurance Annuity Company of New York
Corporate Specialty Markets Administrator Mailing Address:
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 (Mo-Day-Yr) Social Security Number Sex (Circle) Current
/ / - - 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 in the space provided. Yes No
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 Aviation and/or Yes No
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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B10393NY
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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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B10393NY
[LOGO; LINCOLN LIFE](TM)
Lincoln Life & Annuity Company of New York
Administrator Mailing Address: 350 Church St., Hartford, CT 06103-1106
Supplement to Application for
Variable Life Insurance
Supplement to Application - INDIVIDUAL OWNER
1. Proposed Insured ____________________________________________________________
First Middle Last
2. Premium Payment Allocation (Indicate Whole Percentages. Percentages must
equal 100%.)
[American Century Variable Products Group, Inc. Lincoln National Funds
______% VP Income and Growth Fund _____% Bond Fund, Inc.
______% VP International Fund _____% Capital Appreciation Fund, Inc.
American Variable Insurance Series _____% Equity-Income Fund, Inc.
______% Global Growth Fund - Class 2 _____% Money Market Fund, Inc.
______% Growth Fund - Class 2 _____% Social Awareness Fund, Inc.
Baron Capital Funds Trust _____% Fixed Account
_____% Asset Fund MFS Variable Insurance Trust
BT Insurance Funds Trust _____% Research Series
_____% EAFE Equity Index Fund _____% Total Return Series
_____% Equity 500 Index Fund _____% Utilities Series
_____% Small Cap Index Fund _____% Value Series
Delaware Group Premium Fund, Inc. Neuberger & Berman Advisers Management Trust
_____% Delchester Series _____% Mid-Cap Growth Portfolio
_____% Devon Series _____% Partners Portfolio
_____% International Series OCC Accumulation Trust
_____% REIT Series _____% Managed Portfolio
_____% Small Cap Value Series OppenheimerFunds
Fidelity Variable Insurance Products Fund _____% Growth and Income Fund
_____% VIP Growth Portfolio - Service Class Templeton Variable Products Series Fund
_____% VIP II Asset Manager Portfolio - Service Class _____% Asset Allocation Fund - Class 2
_____% VIP II Contrafund Portfolio - Service Class _____% International Fund - Class 2
Janus Aspen Series _____% Stock Fund - Class 2]
_____% Aggressive Growth Portfolio
_____% Balanced Portfolio
_____% Worldwide Growth Portfolio
Owner's Suitability
The rules of the National Association of Securities Dealers, Inc. require that
the Sales Representative have reasonable grounds to believe that the sale is
suitable for the Owner, based on information provided by the Owner as shown on
this form and on information known by the Sales Representative.
3. Owner's Taxpayer Identification Number:
|_| Individual |_||_||_|-|_||_|-|_||_||_||_|
4. Age: ________________________________
5. Citizenship: ________________________________
6. Marital Status: ________________________________
7. Number of Dependents: ________________________________
8. Occupation: ________________________________
9. Employers' Name(s) & Address: ______________________________________________
____________________________________________________________________________
B10394NY
10. Investment Objectives (check all applicable objectives)
|_| Capital Preservation
|_| Tax Advantage/Deferral
|_| Current Income
|_| Growth and Income
|_| Growth
|_| Aggressive Growth
|_| Other (please specify) ___________________________
11. Insurance Objectives (check all applicable objectives)
|_| Estate Creation
|_| Estate Conservation
|_| Other (please specify) ___________________________
12. Investment Knowledge: |_| Limited |_| Good |_| Extensive
13. Risk Tolerance: |_| None |_| Low |_| Medium |_| High
14. Is the coverage in accord with the Owner's insurance objectives and
anticipated financial needs? |_| Yes |_| No
15. Total Income of Owner's Immediate Family
|_| $250,000+
|_| $100,000 - $249,999
|_| $50,000 - $99,999
|_| $25,000 - $49,999
|_| Under $25,000
16. Estimated Net Worth of Owner's Immediate Family
|_| $1,000,000+
|_| $500,000 - $1,000,000
|_| $250,000 - $500,000
|_| $100,000 - $250,000
|_| Under $100,000
17. Federal Tax Bracket: |_| 15% |_| 28% |_| Other (please specify)________
18. Is the Owner associated with a National Association of Securities Dealers,
Inc. firm? |_| Yes |_| No
19. If jointly, or business, owned, please provide the name(s) and signature(s)
of the person(s) authorized to exercise ownership rights:__________________
___________________________________________________________________________
I understand that:
THE AMOUNT AND DURATION OF THE DEATH BENEFIT MAY VARY UNDER SPECIFIED
CONDITIONS.
VALUES NOT IN THE FIXED ACCOUNT MAY INCREASE OR DECREASE IN ACCORDANCE WITH
THE EXPERIENCE OF THE SEPARATE ACCOUNT.
THE AMOUNT OF THE MATURITY BENEFIT IS NOT GUARANTEED BUT IS DEPENDENT UPON
THE THEN SURRENDER VALUE.
ILLUSTRATIONS OF BENEFITS, INCLUDING DEATH BENEFITS, ACCOUNT VALUES, AND
SURRENDER VALUES ARE AVAILABLE UPON REQUEST.
B10394NY
I hereby acknowledge receipt of the Prospectus dated __________________________
for all applicable prospectus(es) pertaining to the Separate Account and all of
the variable options.
Signed at _________________________on _________________________
(City, State) (Mo/Day/Yr)
By ________________________________ By _____________________________________
Signature of Owner Signature of Owner
Based on information obtained from the Owner, I believe the investment is
suitable for the Owner's objectives.
______________________________________ on ________________
Signature of Registered Representative (Mo/Day/Yr)
B10394NY
[LOGO: LINCOLN LIFE](TM)
Lincoln Life & Annuity Company of New York
Administrator Mailing Address: 350 Church St., Hartford, CT 06103-1106
Supplement to Application for
Variable Life Insurance
Supplement to Application - BUSINESS OWNER
1. See attached census for listing of proposed Insureds.
2. Premium Payment Allocation (Indicate Whole Percentages. Percentages must
equal 100%.)
[American Century Variable Products Group, Inc. Lincoln National Funds
______% VP Income and Growth Fund _____% Bond Fund, Inc.
______% VP International Fund _____% Capital Appreciation Fund, Inc.
American Variable Insurance Series _____% Equity-Income Fund, Inc.
______% Global Growth Fund - Class 2 _____% Money Market Fund, Inc.
______% Growth Fund - Class 2 _____% Social Awareness Fund, Inc.
Baron Capital Funds Trust _____% Fixed Account
_____% Asset Fund MFS Variable Insurance Trust
BT Insurance Funds Trust _____% Research Series
_____% EAFE Equity Index Fund _____% Total Return Series
_____% Equity 500 Index Fund _____% Utilities Series
_____% Small Cap Index Fund _____% Value Series
Delaware Group Premium Fund, Inc. Neuberger & Berman Advisers Management Trust
_____% Delchester Series _____% Mid-Cap Growth Portfolio
_____% Devon Series _____% Partners Portfolio
_____% International Series OCC Accumulation Trust
_____% REIT Series _____% Managed Portfolio
_____% Small Cap Value Series OppenheimerFunds
Fidelity Variable Insurance Products Fund _____% Growth and Income Fund
_____% VIP Growth Portfolio - Service Class Templeton Variable Products Series Fund
_____% VIP II Asset Manager Portfolio - Service Class _____% Asset Allocation Fund - Class 2
_____% VIP II Contrafund Portfolio - Service Class _____% International Fund - Class 2
Janus Aspen Series _____% Stock Fund - Class 2]
_____% Aggressive Growth Portfolio
_____% Balanced Portfolio
_____% Worldwide Growth Portfolio
Owner's Suitability
The rules of the National Association of Securities Dealers, Inc. require that
the Sales Representative have reasonable grounds to believe that the sale is
suitable for the Owner, based on information provided by the Owner as shown on
this form and on information known by the Sales Representative.
3. Owner's Taxpayer Identification Number: |_||_|-|_||_||_||_||_||_||_|
Type of Entity:
|_| Corporation |_| S-Corporation |_| Non-Profit Organization
|_| General Partnership |_| Limited Partnership |_| Sole Proprietorship
|_| Other
4. Type of Business:___________________________________________________________
5. Approximate annual income |_| Under $1,000,000
(All Sources) |_| $1,000,001 to $10,000,000
|_| $10,000,001 to $50,000,000
|_| Over $50,000,000
6. Total Assets: |_| Under $1,000,000
|_| $1,000,001 to $10,000,000
|_| $10,000,001 to $50,000,000
|_| Over $50,000,000
B10395 NY
7. Investment Objectives (check all applicable objectives)
|_| Capital Preservation
|_| Tax Advantage/Deferral
|_| Current Income
|_| Growth and Income
|_| Growth
|_| Aggressive Growth
|_| Other (please specify)
8. Please provide a brief description of your insurance objective in
obtaining this coverage:____________________________________________________
____________________________________________________________________________
____________________________________________________________________________
9. Is the Owner associated with a National Association of Securities Dealers,
Inc. firm? |_| Yes |_| No
10. Have the proper corporate resolutions been adopted authorizing the
acquisition of this coverage and exercise of rights thereunder:
|_| Yes |_| No
Lincoln Life reserves the right to require you to provide a copy of such
resolutions.
11. Please identify and provide the name(s) and signatures(s) of the officer(s),
partner(s), or individual(s) authorized to exercise ownership rights:
____________________________________________________________________________
Print Name Title Signature
____________________________________________________________________________
Print Name Title Signature
____________________________________________________________________________
Print Name Title Signature
I understand that:
THE AMOUNT AND DURATION OF THE DEATH BENEFIT MAY VARY UNDER SPECIFIED
CONDITIONS.
VALUES NOT IN THE FIXED ACCOUNT MAY INCREASE OR DECREASE IN ACCORDANCE WITH
THE EXPERIENCE OF THE SEPARATE ACCOUNT.
THE AMOUNT OF THE MATURITY BENEFIT IS NOT GUARANTEED BUT IS DEPENDENT UPON
THE THEN SURRENDER VALUE.
ILLUSTRATIONS OF BENEFITS, INCLUDING DEATH BENEFITS,
ACCOUNT VALUES, AND SURRENDER VALUES ARE AVAILABLE UPON
REQUEST.
I hereby acknowledge receipt of the Prospectus dated for all applicable
prospectus(es) pertaining to the Separate Account and all of the variable
options.
Signed at___________________________on__________________
(City, State) (Mo/Day/Yr)
By _____________________________________ By ______________________________
Signature of Owner Signature of Owner
Based on information obtained from the Owner, I believe the investment is
suitable for the Owner's objectives.
______________________________________ on ______________________________
Signature of Registered Representative (Mo/Day/Yr)
B10395 NY