WELCOME TO

NATIONWIDE LIFE
INSURANCE COMPANY
&
NATIONWIDE LIFE AND
ANNUITY INSURANCE COMPANY

SPECIMEN COPY

VLOB-113 (09/97)

[LOGO] PART I

/ / NATIONWIDE LIFE INSURANCE COMPANY
/ / NATIONWIDE LIFE AND ANNUITY
INSURANCE COMPANY
EMPLOYER-SPONSORED
FLEXIBLE PREMIUM VARIABLE P.O. Box 182150
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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Sex / / M / / F Age Date of Birth / / Birth Place Social Security #
- -
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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 $ ______
/ / Monthly $ ____ / / Semi-Annual $ ______
TARGET SPECIFIED (Electronic Funds Transfer) / / Quarterly $ ______
AMOUNT (Attach completed / / Other $ ______
(INCLUSIVE OF APR) authorization and void
$ ___________ check)
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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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VLOB-113 (09/97)

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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:________

c. Will the insurance applied for replace existing Life Insurance or
Annuities on any person here proposed for insurance?

/ / Yes / / No If Yes, explain ____________________________________
____________________________________
(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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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

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 & DETAILS (BE SPECIFIC. GIVE FULL NAMES, ADDRESSES AND
LETTER DATES 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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Insurance Company Policy Amount Year Accidental To Be Replaced?
Number Issued Death
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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.

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.

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. (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/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