Exhibit 6
NATIONWIDE LIFE INSURANCE COMPANY
LAST SURVIVOR FLEXIBLE PREMIUM VARIABLE UNIVERSAL LIFE INSURANCE APPLICATION P.O. BOX 182835, COLUMBUS, OHIO 43218-2835
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PART A - PAGE 1
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1. INSURED 1
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Name of Insured 1 (first, middle, last) John Doe Sex M Age 35
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State of Birth Any State Date of Birth 10 / 08 / 1966 Social Security Number 000 - 00 - 0000
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Address 1 Any Street
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City Any City State Any State Zip 00000-0000 County Any County
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Telephone - Home ( 000 ) 000-0000 Best Time To Call: A.M. x P.M.
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Telephone - Business ( 000 ) 000-0000 Best Time To Call: x A.M. P.M.
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Driver's License Number/State A00000 / Any State Former Name
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Occupation Principal Annual Earned Income $ 85,000
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Employer Any State School District Kind of Business Education
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Employer's Address 2 Any Street, Any City, Any State 00000-0000
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Length of time in this occupation 10 Yrs. 6 Mos. Citizenship [X] U. S. [ ] Canada [ ] Other (If other, submit Foreign
----- --- Supplement.)
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2. INSURED 2
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Name of Insured 2 (first, middle, last) Jane Doe Sex F Age 33
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State of Birth Any State Date of Birth 02 / 07 / 1968 Social Security Number 000 - 00 - 0000
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Relationship to Insured 1 Wife
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Address 1 Any Street
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City Any City State Any State Zip 00000-0000 County Any County
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Telephone - Home ( 000 ) 000-0000 Best Time To Call: A.M. x P.M.
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Telephone - Business ( 000 ) 000-0000 Best Time To Call: x A.M. P.M.
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Driver's License Number/State A00000 / Any State Former Name Jane Smith
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Occupation Teacher Annual Earned Income $ 45,000
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Employer Any State School District Kind of Business Education
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Employer's Address 2 Any Street, Any City, Any State 00000-0000
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Length of time in this occupation 6 Yrs. 6 Mos. Citizenship [X] U. S. [ ] Canada [ ] Other (If other, submit Foreign
--- ----- Supplement.)
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3. PLAN OF INSURANCE
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PLAN: LAST SURVIVOR FLEXIBLE PREMIUM VARIABLE UNIVERSAL LIFE
Base Amount $ Supplemental Amount $ Total Specified Amount $
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(Total Specified Amount = Base Amount plus Supplemental Amount)
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ADDITIONAL RIDERS (Check all that apply.)
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[ ] Policy Split Option Rider [ ] Maturity Date Extension Endorsement for Specified Amount
[ ] Estate Protection Rider [ ] Other Rider(s)
$
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DEATH BENEFIT OPTION (If no option is selected here, Option 1 is elected.)
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[ ] Option 1 (The Specified Amount, or a multiple of the Cash Value, whichever is greater)
[ ] Option 2 (The Specified Amount, plus the Cash Value, or a multiple of the Cash Value, whichever is greater)
[ ] Option 3 (The Specified Amount, plus the Premium Accumulation at % interest or a multiple of the Cash Value, whichever is
--- greater
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4. TOBACCO USE
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INSURED 1 INSURED 2
A. Have you ever used tobacco or nicotine supplements in any form? [ ] YES [X] NO [ ] YES [X] NO
B. If yes, specify the kind of tobacco or supplement, frequency and date last used. --------------------- --------------------
(cigarettes, pipe, cigars, chewing tobacco, snuff, gum, patch, etc.) --------------------- --------------------
VLOB-0324 (01/2002)
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PART A - PAGE 2
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5. PREMIUM AND MODE
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INITIAL PREMIUM PLANNED PREMIUM
DEPOSIT [ ] SINGLE PREMIUM $ [ ] ANNUAL $
(paid with application) ------------------------ ------------------
[ ] SEMI-ANNUAL $ [ ] QUARTERLY $
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$ [ ] MONTHLY EFT (Complete authorization below.) [ ] $
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ELECTRONIC FUNDS TRANSFER AUTHORIZATION
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Financial Institution Name:
Account Transit/ABA
Number: Number:
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Monthly EFT Amount $ [ ] *Checking (Attach a pre-printed Voided Check. Starter Checks will not be
------------------------------- accepted.)
Draft Date
----------------------------------------- [ ] *Savings (Attach a Voided Deposit Slip with account number and routing
number.)
By providing my financial institution name and account information, I hereby authorize Nationwide Life Insurance Company (hereafter
called the "Company") to initiate debit entries to my checking/savings account indicated above and the Financial Institution to
debit the same such account.
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6. PRIMARY/CONTINGENT BENEFICIARY DESIGNATIONS FOR INSURED 1
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(WHEN MORE THAN ONE BENEFICIARY IS DESIGNATED, PAYMENT TO THE SURVIVORS WILL BE MADE IN EQUAL SHARES, OR IN FULL TO THE LAST
SURVIVOR, UNLESS SOME OTHER DISTRIBUTION OF PROCEEDS IS PROVIDED.)
DATE OF RELATIONSHIP SOCIAL
% PRIMARY CONTINGENT BENEFICIARY NAME BIRTH TO INSURED SECURITY #
[ ] [ ] / / - -
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[ ] [ ] / / - -
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[ ] [ ] / / - -
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[ ] [ ] / / - -
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[ ] [ ] / / - -
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[ ] [ ] / / - -
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7. PRIMARY/CONTINGENT BENEFICIARY DESIGNATIONS FOR INSURED 2
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(WHEN MORE THAN ONE BENEFICIARY IS DESIGNATED, PAYMENT TO THE SURVIVORS WILL BE MADE IN EQUAL SHARES, OR IN FULL TO THE LAST
SURVIVOR, UNLESS SOME OTHER DISTRIBUTION OF PROCEEDS IS PROVIDED.)
DATE OF RELATIONSHIP SOCIAL
% PRIMARY CONTINGENT BENEFICIARY NAME BIRTH TO INSURED SECURITY #
[ ] [ ] / / - -
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[ ] [ ] / / - -
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[ ] [ ] / / - -
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[ ] [ ] / / - -
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[ ] [ ] / / - -
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[ ] [ ] / / - -
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8. OWNER (The Insureds will own the policy jointly, unless otherwise indicated here.)
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Name of Owner (first, middle, last) Date of Birth / /
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Address City State Zip
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Relationship to Insured(s) SS # / Tax ID #
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9. CONTINGENT OWNER (Will be Owner if Owner dies.)
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Name of Owner (first, middle, last) Date of Birth / /
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Address City State Zip
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Relationship to Insured(s) SS # / Tax ID #
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10. PAYOR (If someone other than the Insureds or the Owner is to be billed for the premium on this policy,
list here.)
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Payor's Name and Address
VLOB-0324
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11. INTERNAL REVENUE CODE LIFE INSURANCE QUALIFICATION TEST
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[ ] Guideline Premium/Cash Value Corridor Test [ ] Cash Value Accumulation Test
(If no selection is made here, Guideline Premium/Cash Value Corridor Test is elected.)
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12. SUITABILITY (Must be answered to issue policy.)
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YES NO
A. Do each of you understand that the Death Benefit and Surrender Value may increase or decrease depending on the
investment experience of the Variable Account?...................................................................... [X] [ ]
B. Do each of you believe that this policy will meet your insurance needs and financial objectives?.................... [X] [ ]
C. Have each of you received a current copy of the prospectus?......................................................... [X] [ ]
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13. INSURANCE INFORMATION
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YES NO
A. Will the insurance applied for replace existing Life Insurance or Annuities on either Proposed Insured? (If yes,
provide details in C below.)........................................................................................ [ ] [X]
(Complete and send replacement forms where applicable.)
B. Is either Proposed Insured applying for Life Insurance or Annuities with any other company? (If yes, state the person,
company, kind of policy and Specified Amount being applied for.).................................................... [ ] [X]
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C. List all Life Insurance or Annuities now in force on each Proposed Insured, and any lapsed or surrendered within the
past 5 years. If none, write "NONE".
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TO BE POLICY YEAR ACCIDENTAL NW TERM
REPLACED 1035 INSURED COMPANY NUMBER AMOUNT ISSUED DEATH CONVERSION
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[ ] Yes [ ]No [ ] $ $ [ ]
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[ ] Yes [ ]No [ ] $ $ [ ]
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[ ] Yes [ ]No [ ] $ $ [ ]
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[ ] Yes [ ]No [ ] $ $ [ ]
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(If this is a 1035, please check above and attach 1035 forms. If this is a Nationwide Term Conversion and you are not the Owner
of the term policy or you are not converting the entire amount of the term policy, please enclose a term conversion application.)
VLOB-0324
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PART A - PAGE 3
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14. ALLOCATIONS
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FOR CONTRACTS ISSUED IN STATES WHICH REQUIRE A RETURN OF PREMIUM TO A POLICY OWNER EXERCISING THE SHORT TERM RIGHT TO CANCEL; NET
PREMIUMS WILL BE ALLOCATED TO THE NATIONWIDE SEPARATE ACCOUNT TRUST MONEY MARKET FUND OR TO THE FIXED ACCOUNT IF SELECTED UNTIL THE
END OF THE RIGHT TO CANCEL PERIOD. AT THE END OF THIS PERIOD, YOUR CONTRACT VALUE WILL BE ALLOCATED TO THE SUBACCOUNTS INDICATED
BELOW. FOR STATES REQUIRING A RETURN OF CASH VALUE YOUR NET PREMIUM WILL BE ALLOCATED TO THE SUBACCOUNTS AT THE BEGINNING OF THE
SHORT TERM RIGHT TO CANCEL PERIOD. YOUR SELECTIONS MUST TOTAL 100%. MINIMUM INITIAL ALLOCATION TO ANY SINGLE SUBACCOUNT IS 1%. NO
FRACTIONAL PERCENTAGES. THESE PERCENTAGES WILL APPLY IN FUTURE YEARS BUT MAY BE CHANGED AT ANY TIME BY THE POLICY OWNER. (IF NO
ALLOCATION INDICATED, MONEY MARKET WILL BE AUTOMATICALLY SELECTED.)
MORGAN STANLEY UNIVERSAL STRONG GARTMORE GVIT INVESTOR DESTINATIONS
INSTITUTIONAL % Opportunity Fund II % Aggressive Fund
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100 % Emerging Markets Debt Port. % Conservative Fund
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% Mid Cap Growth Port. FEDERATED INSURANCE SERIES % Moderately Aggressive Fund
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% U. S. Real Estate Port. % Quality Bond Fund II % Moderately Conservative Fund
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% Moderate Fund
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AMERICAN CENTURY FIDELITY (SERVICE CLASS)
% VP Income & Growth % VIP Equity-Income Port. GARTMORE GVIT SUBADVISED FUNDS
- ----- ----- Fund Name (Subadviser)
% VP International % VIP Growth Port. % Balanced Fund (JP Morgan)
- ----- ----- -----
% VP Value % VIP High Income Port. % Equity Income Fund (Federated)
- ----- ----- -----
% VIP Overseas Port. % High Income Bond Fund (Federated)
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NEUBERGER BERMAN % VIP II Contrafund Port. % Mid Cap Growth Fund (Strong)
----- -----
% AMT Guardian Port. % VIP III Growth Opportunities % Mid Cap Index Fund (Dreyfus)
- ----- ----- Port. -----
% AMT Mid-Cap Growth Port. % Multi Sector Bond Fund
- ----- ----- (Miller, Anderson & Sherrerd)
% AMT Partners Port. % Small Cap Growth Fund (Multi
- ----- ----- Managers)
JANUS ASPEN SERIES (SERVICE SHARES) % Small Cap Value Fund (Dreyfus)
DREYFUS % Capital Appreciation Port. -----
----- % Small Company Fund (Multi Managers)
% VIF Appreciation Port. % Global Technology Port. -----
- ----- -----
% Stock Index Fund % International Growth Port.
- ----- -----
% Socially Responsible Growth Fund
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GARTMORE GVIT NATIONWIDE LIFE INSURANCE CO.
OPPENHEIMER % Emerging Markets Fund % Fixed Account
----- -----
% Aggressive Growth Fund/VA % Global Technology and
- ----- ----- Communications Fund
% Capital Appreciation Fund/VA OTHER AVAILABLE FUNDS
- ----- % Government Bond Fund %
% Global Securities Fund/VA ----- ----- ------------------------------------
- ----- % Growth Fund %
% Main Street Growth & Income Fund/VA ----- ----- ------------------------------------
- ----- % International Growth Fund %
----- ----- ------------------------------------
% Money Market Fund
VAN ECK -----
% Total Return Fund
% Worldwide Emerging Markets Fund -----
- ----- % Worldwide Leaders Fund
% Worldwide Hard Assets Fund
- ----- -----
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15. OPTIONAL ELECTIONS (If no election options are chosen, then the election options will be "no".)
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YES NO
A. Do you elect that monthly cost of insurance charges be deducted solely from the Money Market Fund as long as it is
adequately funded?.................................................................................................... [X] [ ]
B. Do you elect Automated Dollar Cost Averaging?......................................................................... [ ] [X]
(If yes, complete Automated Dollar Cost Averaging form.)
C. Do you elect Asset Rebalancing?....................................................................................... [ ] [X]
(If yes, complete Asset Rebalancing form.)
VLOB-0324
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PART A - PAGE 4
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16. PERSONAL INFORMATION
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YES NO
A. Has either Proposed Insured ever had any application for Life or Health Insurance (or for reinstatement of Life or
Health Insurance) declined, postponed, rated-up or limited? (If yes, provide details below.)......................... [ ] [X]
B. Has either Proposed Insured ever applied for or received disability payments for any illness or injury? (If yes,
provide details below.)............................................................................................... [ ] [X]
C. In the past 3 years, has either Proposed Insured engaged in, or intend to engage in:
flying as a pilot, student pilot, or crew member; organized racing of an automobile, motorcycle, or any type of
motor-powered vehicle, scuba diving, mountain climbing, hang gliding, parachuting, sky diving, bungee jumping, or
any type of body-contact or life-threatening sport? (If yes, complete an Aviation/Hazardous Activities
Questionnaire.)..................................................................................................... [ ] [X]
D. Has either Proposed Insured ever had your driver's license suspended or revoked; or been convicted of driving while
impaired or intoxicated, or been convicted in the past three years of more than one moving violation? (If yes, give
full details below.).................................................................................................. [ ] [X]
E. Except as prescribed by a physician, has either Proposed Insured ever used, or been convicted for sale or possession of
cocaine or any other narcotic or illegal drug? (If yes, complete Drug Questionnaire.)................................. [ ] [X]
F. Has either Proposed Insured had any bankruptcies in the past 7 years or have any suits pending or judgments against
them at this time?.................................................................................................... [ ] [X]
G. Has either Proposed Insured ever been convicted of a felony, misdemeanor, or any other crime? (If yes, provide details
below.)............................................................................................................... [ ] [X]
H. Does either Proposed Insured plan to travel or reside outside of the United States or Canada? (If yes, complete
Supplement for Foreign Nationals or Travel.).......................................................................... [ ] [X]
I. Physician's Name, Address, and Phone Number for Insured 1, DATE AND REASON LAST CONSULTED.
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J. Physician's Name, Address, and Phone Number for Insured 2, DATE AND REASON LAST CONSULTED.
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Details of any yes answers:
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17. SPECIAL INSTRUCTIONS/HOME OFFICE ENDORSEMENTS
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VLOB-0324
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PART B
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1. PHYSICAL MEASUREMENTS
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INSURED HEIGHT WEIGHT CURRENT WEIGHT 1 YR AGO REASON FOR WEIGHT GAIN OR LOSS
- --------------- ----------------- --------------------- --------------------- -----------------------------------------------------
Insured 1 6 Ft. 2 In. 185 Lbs. 185 Lbs.
- --------------- ----------------- --------------------- --------------------- -----------------------------------------------------
Insured 2 5 Ft. 8 In. 130 Lbs. 130 Lbs.
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2. MEDICAL QUESTIONS (For each yes answer, check the appropriate item, and provide details in number 5 below.)
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To the best of your knowledge and belief, in the past 10 years has either Proposed Insured been treated for, taken
medication for or been diagnosed by the medical profession as having: YES NO
A. Heart attack, angina, or other chest pain, high blood pressure, shortness of breath, palpitations, heart murmur,
phlebitis, or any other disorder of the heart or blood vessels?....................................................... [ ] [X]
B. Headaches, seizures, epilepsy, stroke, Alzheimer's disease, Parkinson's disease, multiple sclerosis, or depression,
neurosis, affective disorder, psychosis, or any other brain, nervous, or mental disorder?............................. [ ] [X]
C. Asthma, emphysema, tuberculosis, chronic bronchitis, or any other disease of the lungs or respiratory system?......... [ ] [X]
D. Any disease or disorder of the eyes, ears, nose or throat?............................................................ [ ] [X]
E. Colitis, ulcer, persistent diarrhea, rectal bleeding, or any other disease or disorder of the digestive tract?........ [ ] [X]
F. Kidney stones, nephritis, sugar, protein or blood in the urine, sexually transmitted diseases, any disease or disorder
of the kidneys, bladder, prostate, or breasts, or any other disease of the urinary tract or reproductive system?...... [ ] [X]
G. Diabetes, hepatitis, cirrhosis, or any other disease of the liver, pancreas, or thyroid?.............................. [ ] [X]
H. Cancer, or any malignant or benign tumor or cyst, or any chronic disease of the skin or lymph glands?................. [ ] [X]
I. Arthritis, rheumatoid arthritis, osteoporosis, gout, or any paralysis or chronic back or muscle condition?............ [ ] [X]
J. Alcoholism, alcohol use, narcotic addiction, drug use, or hallucinations?............................................. [ ] [X]
K. AIDS (Acquired Immune Deficiency Syndrome), or any other AIDS-related condition, or received a positive result of an
HIV (Human Immunodeficiency Virus) test?.............................................................................. [ ] [X]
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3. SUPPLEMENTAL MEDICAL INFORMATION (For each yes answer, check the appropriate item, and provide details in number 5 below.)
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Within the past five years, has either Proposed Insured: YES NO
A. Consulted, or been examined or treated by any physician, chiropractor, or other medical practitioner or by any
hospital, clinic, or other medical facility not previously mentioned? ................................................ [ ] [X]
(If it was for a "check up", annual physical, employment physical, etc., so state and give findings and results in #5
below.)
B. Had any disease, disorder, injury, or operation not previously mentioned?............................................. [ ] [X]
C. Had any x-rays, electrocardiograms, or other medical tests for reasons not covered above?............................. [ ] [X]
D. Been advised to have any surgery, hospitalization, treatment, or test that was not completed?......................... [ ] [X]
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4. FAMILY HISTORY
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YES NO
Has either parent, or any sibling, of either Proposed Insured, experienced death prior to age 60 due to cardiovascular
disease or cancer?......................................................................................................... [ ] [X]
(If yes, provide name of Insured, relationship to Insured, age at death, cause, and location of tumor if due to cancer.)
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5. DETAILS OF MEDICAL HISTORY
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QUESTION # DETAILS - GIVE DATES, CONDITION, TREATMENT, RESULTS, PHYSICIAN AND/OR HOSPITAL
AND LETTER DATES INSURED NAMES, ADDRESSES AND TELEPHONE NUMBERS, ETC.
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VLOB-0324
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PART C
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TAXPAYER IDENTIFICATION NUMBER
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Under the Interest and Dividend Compliance Act of 1983, persons owning insurance policies are required to provide the Company with
certification that their taxpayer identification number is correct. (For most individuals, this is their Social Security
Number.) If you do not provide us with certification of this number, you may be subject to a $50 penalty imposed by the Internal
Revenue Service. In addition, we will be forced to withhold 31% from interest and other payments we make to you (known as backup
withholding). It is not an additional tax, since the amount withheld may be applied against any tax you owe. If withholding
results in an overpayment of taxes, a refund may be available.
[ ] Check this box if the Internal Revenue Service has notified you that you are subject to backup withholding.
OTHERWISE, YOUR SIGNATURE ON THIS APPLICATION IS CERTIFICATION THAT THE TAXPAYER IDENTIFICATION NUMBER ON THIS APPLICATION IS
TRUE, CORRECT, AND COMPLETE. THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER
THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING.
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IMPORTANT NOTICE
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I UNDERSTAND THAT THE DEATH BENEFIT UNDER A VARIABLE LIFE INSURANCE POLICY MAY INCREASE OR DECREASE, DEPENDING ON THE INVESTMENT
RETURN ON THE SUBACCOUNT(S) I SELECT. REGARDLESS OF INVESTMENT RETURN, THE DEATH BENEFIT CAN NEVER BE LESS THAN THE SPECIFIED
AMOUNT, AS LONG AS THE POLICY IS IN FORCE. THE CONTRACT VALUE MAY INCREASE OR DECREASE ON ANY DAY, DEPENDING ON THE INVESTMENT
RETURN FOR THE POLICY. NO MINIMUM CONTRACT VALUE IS GUARANTEED. ON REQUEST, WE WILL FURNISH ILLUSTRATIONS OF BENEFITS, INCLUDING
DEATH BENEFITS AND CONTRACT VALUES FOR A VARIABLE LIFE INSURANCE POLICY AND A FIXED LIFE INSURANCE POLICY FOR THE SAME PREMIUM.
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AGREEMENT, AUTHORIZATION AND SIGNATURES
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I have read this application. I understand each of the questions. All of the answers and statements on this form are complete
and true to the best of my knowledge and belief. I understand and agree that:
A. This application, any amendments to it, and any related medical examinations will become a part of the Policy and are the
basis of any insurance issued upon this application.
B. Any person who submits an application or a claim containing a false or deceptive statement, and does so with intent to defraud
or knowing that he/she is facilitating a fraud against an insurer, is guilty of insurance fraud.
C. No medical examiner and no producer of Nationwide may accept risks or make or change any contract, or waive or change any of
the Company's rights or requirements.
D. If the full first premium payment is made in exchange for a Temporary Insurance Receipt (with the same date and number as this
form), Nationwide will only be liable to the extent set forth in that receipt.
E. IF THE FULL FIRST PREMIUM IS NOT PAID WITH THIS APPLICATION, THEN INSURANCE WILL ONLY TAKE EFFECT WHEN ALL OF THE FOLLOWING
CONDITIONS ARE MET:
1. IF A POLICY IS ISSUED BY NATIONWIDE AND IS ACCEPTED BY ME; AND
2. IF THE FULL FIRST PREMIUM IS PAID; AND
3. IF ALL THE ANSWERS AND STATEMENTS MADE ON THE APPLICATION, MEDICAL EXAMINATION(S) AND AMENDMENTS CONTINUE TO BE TRUE TO
THE BEST OF MY KNOWLEDGE AND BELIEF.
I have received the pre-notice form of the Fair Credit Reporting Act of 1970 and the Medical Information Bureau disclosure form.
I certify that the Social Security Number given is correct and complete.
I authorize: any licensed physician or medical practitioner; any hospital, clinic or other medical or medically related facility;
any insurance company; the Medical Information Bureau; or any other organization, institution or person who has knowledge of me;
to give that information to the Medical Director of the Nationwide Life Insurance Company, or its reinsurers. This authorization,
or a copy of it, will be valid for a period of not more than two and one-half years (30 months) from the date it was signed.
Signed at Any City, Any State , on January 3 , 2002 .
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City/State Month/Day Year
I have truly and accurately recorded all Proposed Insured's answers
on this application and have witnessed his/her/their signature(s)
hereon. John Doe
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To the best of my knowledge, the insurance applied for [ ] will Name of Insured 1
[X] will not (CHECK ONE) replace any life, health, and/or
annuity. John Doe
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Signature of Insured 1
Ed Agent Any Firm
- -------------------------------------------------------------------- Jane Doe
Producer's Name (Print) Firm -------------------------------------------------------------
Name of Insured 2
Ed Agent 000-000-0000 Jane Doe
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Producer's Signature SSN Signature of Insured 2
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Signature of Applicant/Owner (if other than the Insured)
VLOB-0324
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PART D
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IMPORTANT NOTICE
DETACH AND GIVE TO PROPOSED INSURED
PRE-NOTICE OF PROCEDURES AS REQUIRED BY THE FAIR CREDIT REPORTING ACT OF 1970
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This notice is to inform you that as part of our normal underwriting procedures in connection with an application for insurance:
A. An investigative consumer report may be made whereby information is obtained through personal interviews with your neighbors,
friends or others with whom you are acquainted. This inquiry will include information as to character, general reputation,
personal characteristics and mode of living, except as may be related directly or indirectly to your sexual orientation, with
respect to you, members of your family, and others having an interest in or closely connected with the insurance transaction;
and
B. Upon your written request, made within a reasonable time after you receive this notice, additional information as to the
nature and scope of the investigation, if one is made, will be provided. Requests for additional information should be
addressed to Nationwide Life Insurance Company, P.O. Box 182835, Columbus, Ohio 43218-2835.
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MEDICAL INFORMATION BUREAU DISCLOSURE NOTICE
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Information regarding your insurability will be treated as confidential. Nationwide Life Insurance Company, or its reinsurer(s)
may, however, make a brief report thereon to the Medical Information Bureau, a non-profit membership organization of life
insurance companies, which operates an information exchange on behalf of its members. If you apply to another Bureau member
company for life or health insurance coverage or a claim for benefits is submitted to such a company, the Bureau, upon request,
will supply such company with the information in its file.
Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If you
question the accuracy of information in the Bureau's file, you may contact the Bureau and seek a correction in accordance with the
procedures set forth in the Federal Fair Credit Reporting Act. The address of the Bureau's information office is Post Office Box
105, Essex Station, Boston, Massachusetts 02112, telephone number (617) 426-3660.
Nationwide Life Insurance Company or its reinsurer(s) may also release information in its file to other life insurance companies
to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted.
VLOB-0324
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PART E
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TEMPORARY INSURANCE AGREEMENT
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NATIONWIDE LIFE INSURANCE COMPANY, COLUMBUS, OHIO
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HEALTH QUESTION
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Has either Proposed Insured: YES NO
within the past 10 years, been treated for, consulted a physician, or been diagnosed by a physician as having: angina, or
chest pain or discomfort; heart attack, heart murmur, or any other heart disorder; epilepsy, stroke or diabetes; Acquired
Immune Deficiency Syndrome (AIDS), any AIDS-related disorder or positive HIV (Human Immunodeficiency Virus) test result;
any brain, nervous, or mental disorder, any drug or alcohol addiction; any kidney disorder (other than kidney stones); or
any cancer or other malignancy?......................................................................................... [ ] [X]
If the above question is answered YES or LEFT BLANK, NO COVERAGE will take effect under this Agreement and no representative of
Nationwide Life Insurance Company is authorized to accept money, and/or provide a temporary insurance receipt to the applicant.
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RECEIPT
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This Agreement provides a limited amount of life insurance coverage, for a limited period of time, subject to the terms of this
Agreement. Advance payment in the amount of $ 324.83 is made for $ 100,000 death benefit (Specified Amount on the
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application or $1,000,000 whichever is less) on the lives of John Doe Jane Doe
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NAME OF PROPOSED INSURED
NOTE: MAKE ALL CHECKS PAYABLE TO NATIONWIDE. DO NOT MAKE CHECKS PAYABLE TO THE PRODUCER OR LEAVE THE PAYEE BLANK.
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TERMS AND CONDITIONS
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AMOUNT OF COVERAGE - $1,000,000 OVERALL MAXIMUM FOR ALL APPLICATIONS OR AGREEMENTS
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If money has been accepted by Nationwide as advance payment for an application for Life Insurance and any Proposed Insured dies
while this temporary insurance is in effect, Nationwide will pay to the designated beneficiary the lesser of (a) the amount of death
benefits, if any, which would be payable under the policy and its riders if issued as applied for, excluding any accidental death
benefits, or (b) $1,000,000. This total benefit limit applies to all insurance applied for under this and any other current
applications to Nationwide and any other Temporary Insurance Agreements for Life Insurance whether applied for on the life or lives
of one or more Proposed Insureds. (NOTE: No death benefit is payable under this Agreement for any Last Survivor coverages unless
both Proposed Insureds under such coverages had died.)
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DATE COVERAGE TERMINATES - 60 DAY MAXIMUM COVERAGE
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Temporary Life Insurance under this Agreement will terminate automatically on the earliest of:
A. 60 DAYS from the date of this Agreement, or
B. the date any policy is offered to the Applicants in connection with the above application, or
C. five days after the date, Nationwide mails notice of termination of coverage and refund of the advance payment to the premium
notice address designated in such application.
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LIMITATIONS
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This Agreement does not provide benefits unless a full first premium for the mode selected has been paid at the time of this
application.
Fraud or material misrepresentation in the application or in the answers to the Health questions of this Agreement invalidate this
agreement and Nationwide's only liability is for refund of any payment made.
No one is authorized to accept money on Proposed Insureds under 15 days of age or over the age of 70 (nearest birthday) on the
date of the Agreement, nor will any coverage take effect.
If any Proposed Insured dies by suicide, Nationwide's liability under this Agreement is limited to a refund of the payment made.
There is no coverage under this Agreement if the check submitted as payment is not honored by the bank on first presentation.
No one is authorized to waive or modify any of the provisions of this Agreement.
I HAVE RECEIVED A COPY OF AND HAVE READ THIS AGREEMENT AND DECLARE THAT THE ANSWERS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND
BELIEF. I UNDERSTAND AND AGREE TO ALL ITS TERMS.
Dated 01 03 2002 X John Doe
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MONTH DAY YEAR SIGNATURE OF INSURED 1
Ed Agent X Jane Doe
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SIGNATURE OF PRODUCER SIGNATURE OF INSURED 2
X
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APPLICANT/OWNER'S SIGNATURE (IF OTHER THAN INSURED)
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NOTICE TO APPLICANT
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You should retain copy 2 of this Agreement. The original must remain with the application and will be retained by Nationwide.
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or
files a claim containing a false or deceptive statement is guilty of insurance fraud.
VLOB-0324 COPY 1 - SEND TO HOME OFFICE WITH APPLICATION COPY 2 - RETAINED BY PROPOSED INSURED