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Exhibit 6
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WELCOME TO
NATIONWIDE LIFE
INSURANCE COMPANY
SPECIMEN COPY
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[NATIONWIDE INSURANCE LOGO]
PART I
NATIONWIDE LIFE INSURANCE COMPANY
EMPLOYER-SPONSORED P.O. BOX 182150
FLEXIBLE PREMIUM VARIABLE UNIVERSAL LIFE COLUMBUS, OHIO 43218-2150
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1. EMPLOYER INFORMATION
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Employer Name Taxpayer ID Number
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Address (City, State, Zip Code)
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2. INSURED
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Name of Insured (First, Middle, Last) Home Telephone Business Telephone
( ) ( )
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Social Security
Sex [ ] M [ ] F Age Date of Birth / / Birth Place Number - -
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Street Address City State Zip Code County
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3. OWNER (If other than Employer)
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Full Name Date of Birth Relationship to Insured
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Address Social Sec or Tax ID Number
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4. BENEFICIARY (If other than Employer)
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FULL NAME OF DATE OF RELATIONSHIP SOCIAL
BENEFICIARY ADDRESS BIRTH TO INSURED SECURITY #
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5. SPECIFIED AMOUNT AND PREMIUM PLAN
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SPECIFIED AMOUNT PLANNED PREMIUM
$ [ ] Employer List Bill $ [ ]Annual $
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[ ] Monthly $ [ ]Semi-Annual $
TARGET SPECIFIED AMOUNT ------------------ -----------------------
(INCLUSIVE OF APR) (Electronic Funds Transfer) [ ]Quarterly $
(Attach completed authorization -----------------------
$ and void check) [ ]Other $
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6. OPTIONAL BENEFIT RIDERS
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[ ] Additional Protection Rider (Attach Schedule of Target Specified Amounts, if applicable)
[ ] Other
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7. DEATH BENEFIT OPTION
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[ ] OPTION 1 (The Specified Amount, or a multiple of the Contract Value, whichever is greater.)
[ ] OPTION 2 (The Specified Amount, plus premium Contract Value, or a multiple of the Contract
Value, whichever is greater.)
[ ] OPTION 3 (The Specified Amount, plus the premium accumulation at _________% interest or a multiple of the
Contract Value, whichever is greater.)
(IF NO OPTION IS SELECTED, OPTION 1 IS ELECTED.)
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8. SUPPLEMENTAL INFORMATION
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a. Have you been actively at work daily on a full-time basis (minimum 30 hours per week) for the past 3 months? (Disregard
vacation days and absences that total less than 5 days.)
[ ]Yes [ ]No If No, explain and complete PART II
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b. Have you used any tobacco products in the past 12 months?
[ ]Yes [ ]No If Yes, specify Type: Frequency:
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c. Will the insurance applied for replace existing Life Insurance or Annuities
on any person here proposed for insurance? [ ]Yes [ ]No If Yes, explain
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(Complete and send replacement forms where applicable.)
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9. SUITABILITY
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YES NO
a. Do you understand that the Death Benefit and Surrender Value may increase or decrease depending
on the investment experience of the Variable Account?............................................................. [ ] [ ]
b. Do you believe that this policy will meet your insurance needs and financial objectives?.......................... [ ] [ ]
c. Have you received a current copy of the prospectus?............................................................... [ ] [ ]
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10. 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.)
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NEUBERGER & BERMAN OPPENHEIMER VARIABLE ACCOUNTS FUND DREYFUS, INC.
ADVISERS MANAGEMENT TRUST _____ % Bond Fund _____ % Stock Index Fund
_____ % Limited Maturity Bond Port. _____ % Multiple Strategies Fund _____ % Socially Responsible
_____ % Growth Port. _____ % Global Securities Fund Growth Fund
_____ % Partners Port. _____ % Growth Fund _____ % VIF Capital Appreciation
Port.
MORGAN STANLEY UNIVERSAL FIDELITY VIP FUNDS _____ % VIF Growth & Income Port.
FUNDS, INC. _____ % High Income Port.
_____ % Emerging Markets Debt _____ % Equity-Income Port. NATIONWIDE SEPARATE ACCOUNT TRUST
Port. _____ % Growth Port. _____ % Money Market Fund
_____ % Overseas Port. _____ % Government Bond Fund
WARBURG PINCUS TRUST _____ % Asset Manager Port. _____ % Total Return Fund
_____ % International Equity Port. _____ % Contrafund Port. _____ % Capital Appreciation Fund
_____ % Small Company Growth Port. _____ % Growth Opportunities Port. _____ % Small Company Fund
_____ % Post-Venture Capital Port.
AMERICAN CENTURY VARIABLE PORTFOLIOS, VAN ECK WORLDWIDE INSURANCE TRUST
VAN KAMPEN AMERICAN CAPITAL INC. _____ % Worldwide Hard Assets Fund
LIFE INVESTMENT TRUST _____ % VP Capital Appreciation _____ % Worldwide Bond Fund
_____ % Morgan Stanley Real Estate _____ % VP Balanced _____ % Worldwide Emerging Markets
Securities Port. _____ % VP International Fund
_____ % VP Value
STRONG VARIABLE INSURANCE OTHER AVAILABLE FUNDS
FUNDS, INC. NATIONWIDE LIFE _____ % __________________________
_____ % Discovery Fund II INSURANCE CO. _____ % __________________________
_____ % Opportunity Fund II _____ % Fixed Account
_____ % International Stock Fund II
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11. 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 will be applied against the tax you
owe. If withholding results in an overpayment of taxes, a refund may be
obtained.
[ ] Check this box if the Internal Revenue Service has notified you that you
are NOT subject to the provisions of this law. Otherwise, your signature
on this application is certification that the taxpayer identification
number on this application is true, correct, and complete.
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12. 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 OF 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:
1. This application and any amendments to it, will become a part of the
Policy. They are the basis of any insurance issued upon this application.
2. 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.
3. No agent or other representative of Nationwide may accept risks or make or
change any contract, or waive or change any of the Company's rights or
requirements.
4. No information will be considered as having been given to Nationwide unless
it is written in this application.
5. Insurance will only take effect when all of the following conditions are
met:
a. If a Policy is issued by Nationwide and is accepted by me; and
b. If the full first premium is paid; and
c. If all the answers and statements made on the application and
amendments continue to be true to the best of my knowledge and belief.
Signed at , on , .
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Signature of Proposed Insured Signature of Owner
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I have truly and accurately recorded all Proposed Insured's answers on this
application and have witnessed his/her/their signature(s) hereon.
To the best of my knowledge, the insurance applied for [ ] will [ ] will not
(CHECK ONE) replace any life insurance or annuity.
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Licensed Resident Agent Signature Firm Agent's Name (Print) License ID Number
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PART II
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13. PERSONAL INFORMATION
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YES NO
a. Have you 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.)
b. Have you ever applied for or received disability payments for any illness or injury?.............................. [ ] [ ]
(If "Yes", provide details below.)
c. Has either of your natural parents suffered cardiovascular disease or death prior to age 60?...................... [ ] [ ]
d. Have you 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", provide details, driver's license #, and state of issue below.)
e. Have you ever been convicted of a felony, misdemeanor, or any other crime or have you ever used
drugs other than as prescribed by a physician?.................................................................... [ ] [ ]
(If "Yes", provide details below.)
f. In the past 3 years have you engaged in, or do you intend to engage in: flying as a pilot, student pilot,
or crew member; 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.)
DETAILS:
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14. MEDICAL QUESTIONS AND INFORMATION
(For each "yes" answer circle the appropriate item and provide details in #15 below.)
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YES NO
To the best of your knowledge and belief, in the past 10 years have you been
treated for or been diagnosed by a member of the medical profession as having:
a. Alcoholism, drug use other than as prescribed by a physician, nervous or mental disorder?......................... [ ] [ ]
b. High blood pressure, epilepsy or stroke, Alzheimer's disease, disease of the pancreas or lymph glands,
blood disorder?................................................................................................... [ ] [ ]
c. Chest pains, heart attack or other heart disorder, diabetes, kidney disorder, lung or respiratory disorder
or any cancer or malignancy?...................................................................................... [ ] [ ]
d. AIDS (Acquired Immune Deficiency Syndrome), ARC (AIDS-related complex), or any other AIDS-related.................
condition, or received a positive result of an HIV test?.......................................................... [ ] [ ]
e. Any chronic or persistent disease not mentioned previously?....................................................... [ ] [ ]
Within the past five years, have you:
f. 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?................................... [ ] [ ]
g. Had any disease, disorder, injury, or operation not previously mentioned?......................................... [ ] [ ]
Within the past two years, have you:
h. Taken or do you currently take any prescription medication (If so, state name of drug, reason for taking
drug and frequency below)?........................................................................................ [ ] [ ]
i. Been advised to have any surgery, hospitalization, treatment or test that was not completed?...................... [ ] [ ]
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15. DETAILS OF MEDICAL HISTORY
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QUESTION NUMBER
& LETTER DATES DETAILS (BE SPECIFIC. GIVE FULL NAMES, ADDRESSES AND TELEPHONE
NUMBER, IF AVAILABLE, OF PHYSICIANS, HOSPITALS, ETC.)
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16. PERSONAL PHYSICIAN INFORMATION
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Name, address, and phone number of Personal Physician
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Date last consulted, reason and results
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Proposed Insured's Height: Weight:
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17. INSURANCE INFORMATION
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List all Life Insurance now in force on Proposed Insured. If none, write "NONE".
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Year Accidental
Insurance Company Policy Number Amount Issued Death To Be Replaced?
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18. SPECIAL INSTRUCTIONS
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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:
1. This application and any amendments to it, and any related medical
examinations will become a part of the Policy. They are the basis of any
insurance issued upon this application.
2. 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.
3. No medical examiner or no agent or other representative of Nationwide may
accept risks or make or change any contract, or waive or change any of the
Company's rights or requirements.
4. Insurance will only take effect when all of the following conditions are
met:
a. If a Policy is issued by Nationwide and is accepted by me; and
b. If the full first premium is paid; and
c. If all the answers and statements made on the application 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.
Also, the Medical Information Bureau disclosure form has been given to me. 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 Insurance Company, or its reinsurers. This authorization, or a copy
of it, will be valid for a period of not more than one year from the date it was
signed.
Signed at , on , .
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Signature of Proposed Insured
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I have truly and accurately recorded all Proposed Insured's answers on this
application and have witnessed his/her/their signature(s) hereon.
To the best of my knowledge, the insurance applied for [ ] will [ ] will not
(CHECK ONE) replace any life insurance or annuity.
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Licensed Resident Agent Signature Firm Agent's Name (Print) License ID Number
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PROVIDE TO PROPOSED INSURED ONLY IF PART II OF APPLICATION IS COMPLETED
IMPORTANT NOTICE
DETACH AND GIVE TO PROPOSED INSURED
PRE-NOTICE OF PROCEDURES AS REQUIRED BY THE FAIR CREDIT REPORTING ACT OF 1970
This notice is to inform you that as part of our normal underwriting procedures
in connection with an application for insurance:
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
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, Box 182150, Columbus, Ohio
43218-2150.
MEDICAL INFORMATION BUREAU DISCLOSURE NOTICE
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. (Medical information will be disclosed
only to your attending physician.) 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.