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EXHIBIT 6
WELCOME TO
NATIONWIDE LIFE
INSURANCE COMPANY
&
NATIONWIDE LIFE AND
ANNUITY INSURANCE COMPANY
SPECIMEN COPY
VLOB-113 (06/98)
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[NATIONWIDE INSURANCE LOGO]
PART I
| | Nationwide Life Insurance Company
| | Nationwide Life and Annuity
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 $ -----------------------
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Target Specified Amount (Electronic Funds Transfer) | |Quarterly $ -----------------------
(Inclusive of APR) (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
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Contract Value, whichever is greater.)
(IF NO OPTION IS SELECTED, OPTION 1 IS ELECTED.)
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VLOB-113 (06/98)
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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
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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DREYFUS, INC. OPPENHEIMER VARIABLE NATIONWIDE SEPARATE
% Socially Responsible Growth Fund ACCOUNTS FUND ACCOUNT TRUST
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% Stock Index Fund % Aggressive Growth Fund % Capital Appreciation Fund
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% VIF Capital Appreciation Port. % Bond Fund % Government Bond Fund
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% VIF Disciplined Stock Port. % Global Securities Fund % Money Market Fund
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% VIF International Value Port % Growth Fund % Small Company Fund
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% VIF Limited Term High Income Port. % Growth & Income Fund % Total Return Fund
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% VIF Quality Bond Port. % High Income Fund
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% VIF Small Company Stock Port. % Multiple Strategies Fund OTHER AVAILABLE FUNDS
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% Small Cap Growth Fund ----- % --------------------------------
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% Strategic Bond Fund ----- % --------------------------------
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VLOB-113
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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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VLOB-113
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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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VLOB-113
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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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VLOB-113
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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/Nationwide Life and Annuity 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/Nationwide Life and
Annuity 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/Nationwide Life and Annuity 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-113