EX-99.5 4 0004.txt APPLICATION ============================== -------------- The Lincoln National Life Logo ChoicePlus Bonus Insurance Company -------------- Variable Annuity Application Fort Wayne, Indiana ============================== ==================================================================================================================================== Instructions: Please type or print. ANY ALTERATIONS TO THIS APPLICATION MUST BE INITIALED BY THE CONTRACT OWNER. ------------------------------------------------------------------------------------------------------------------------------------ 1a Contract Owner ------------------------------------------------------------------------------------------------------------------------------------ _______________________________________ Social Security number/TIN [_][_][_]-[_][_]-[_][_][_][_] Full legal name or trust name* Date of birth [_][_] [_][_] [_][_] [_] Male [_] Female Month Day Year _______________________________________ Street address Home telephone number [_][_][_] [_][_][_]-[_][_][_][_] _______________________________________ City State ZIP Date of trust* [_][_] [_][_] [_][_] Is trust revocable?* Month Day Year [_] Yes [_] No _______________________________________ Trustee name* Note: Maximum age of Contract Owner is 85. *This information is required for trusts. ------------------------------------------------------------------------------------------------------------------------------------ 1b Joint Contract Owner ------------------------------------------------------------------------------------------------------------------------------------ Social Security number [_][_][_]-[_][_]-[_][_][_][_] _______________________________________ Full legal name [_] Male [_] Female Note: Maximum age of Joint Contract Owner is 85. Date of birth [_][_] [_][_] [_][_] Month Day Year [_] Spouse [_] Non-spouse ------------------------------------------------------------------------------------------------------------------------------------ 2a Annuitant (If no Annuitant is specified, the Contract Owner, or Joint Owner if younger, will be the Annuitant.) ------------------------------------------------------------------------------------------------------------------------------------ Social Security number [_][_][_]-[_][_]-[_][_][_][_] _______________________________________ Full legal name Date of birth [_][_] [_][_] [_][_] [_] Male [_] Female Month Day Year _______________________________________ Street address Home telephone number [_][_][_] [_][_][_]-[_][_][_][_] _______________________________________ City State ZIP Note: Maximum age of Annuitant is 85. ------------------------------------------------------------------------------------------------------------------------------------ 2b Contingent Annuitant ------------------------------------------------------------------------------------------------------------------------------------ Social Security number [_][_][_]-[_][_]-[_][_][_][_] _______________________________________ Full legal name Note: Maximum age of Annuitant is 90. ------------------------------------------------------------------------------------------------------------------------------------ 3 Beneficiary(ies) of Contract Owner (List additional beneficiaries on separate sheet. If listing children, use full legal names.) ------------------------------------------------------------------------------------------------------------------------------------ __________________________________________________ ____________________________________ ________________ _________% Full legal name [_] Primary [_] Contingent Relationship to Contract Owner SSN/TIN or trust name* __________________________________________________ ____________________________________ ________________ _________% Full legal name [_] Primary [_] Contingent Relationship to Contract Owner SSN/TIN or trust name* __________________________________________________ ____________________________________ ________________ _________% Full legal name [_] Primary [_] Contingent Relationship to Contract Owner SSN/TIN or trust name* __________________________________________________ Date of trust* [_][_] [_][_] [_][_] Is trust revocable?* Trustee name* Month Day Year [_] Yes [_] No *This information is required for trusts. To specify an annuity payment option for your beneficiary, please complete the Beneficiary Payment Options form (29953CP). ------------------------------------------------------------------------------------------------------------------------------------ 4 Type of Lincoln ChoicePlus(SM) Variable Annuity Contract ------------------------------------------------------------------------------------------------------------------------------------ Nonqualified: [_] Initial Contribution OR [_] 1035 Exchange Tax-Qualified (must complete plan type): [_] Transfer OR [_] Rollover Plan Type (check one): [_] Roth IRA [_] Traditional IRA
Form 29365-Bonus 4/00 [CP-APP] Page 1 ------------------------------------------------------------------------ 5a Allocation (This section must be completed.) ------------------------------------------------------------------------ Initial minimum: $10,000 Future contributions will follow the allocation below. If DCA option is selected, the entire amount of each future contribution will follow the allocation in Section 5b. If no allocations are specified in Section 5a or 5b, the entire amount will be allocated to the Money Market Fund pending instructions from the contract owner. ------------------------------------------------------------------------ Total initial contribution amount $ _______________ Total DCA amount $ _______________ (enter amount in Section 5b) Remaining amount to be allocated $ _______________ ------------------------------------------------------------------------ INTO THE FUND(S) BELOW ------------------------------------------------------------------------ Use whole percentages ______________% Delaware Emerging Markets Series ______________% Delaware Growth & Income Series ______________% Delaware High Yield Series ______________% Delaware REIT Series ______________% Delaware Select Growth Series ______________% Delaware Small Cap Value Series ______________% Delaware Social Awareness Series ______________% Delaware Trend Series ______________% AIM V.I. Capital Appreciation Fund ______________% AIM V.I. Growth Fund ______________% AIM V.I. International Fund ______________% AIM V.I. Value Fund ______________% Alliance Growth Portfolio ______________% Alliance Growth & Income Portfolio ______________% Alliance Premier Growth Portfolio ______________% Alliance Technology Portfolio ______________% American Funds Global Small Cap Fund ______________% American Funds Growth Fund ______________% American Funds Growth-Income Fund ______________% American Funds International Fund ______________% Deutsche VIT Equity 500 Index Fund ______________% Fidelity VIP Equity Income Portfolio ______________% Fidelity VIP Growth Portfolio ______________% Fidelity VIP Overseas Portfolio ______________% Fidelity VIP III Growth Opportunities Portfolio ______________% Franklin Templeton Growth Securities Fund ______________% Franklin Templeton International Securities Fund ______________% Franklin Templeton Mutual Shares Securities Fund ______________% Franklin Templeton Small Cap Securities Fund ______________% Liberty Newport Tiger Fund ______________% Lincoln National Bond Fund ______________% Lincoln National Money Market Fund ______________% MFS Emerging Growth Series ______________% MFS Research Series ______________% MFS Total Return Series ______________% MFS Utilities Series Fixed Account: ___________ % 5 years __________ % 1 year ___________ % 7 years ___________% 3 years ___________ % 10 years % Total (must = 100%) ============== ------------------------------------------------------------------------ ------------------------------------------------------------------------ 5b Dollar Cost Averaging (Complete only if electing DCA.) ------------------------------------------------------------------------ $2,000 minimum required. ------------------------------------------------------------------------ Total amount to DCA: $ _____________________ OR MONTHLY amount to DCA: $ _____________________ ------------------------------------------------------------------------ OVER THE FOLLOWING PERIOD: _____________________ MONTHS (6-60) ------------------------------------------------------------------------ FROM THE FOLLOWING HOLDING ACCOUNT (check one): [_] 1 Year Fixed Account (Only available for 12 months or less.) [_] Delaware High Yield Series* [_] Lincoln National Money Market Fund* *The DCA holding account [_] Lincoln National Bond Fund* and the DCA fund elected cannot be the same. ------------------------------------------------------------------------ INTO THE FUND(S) BELOW ------------------------------------------------------------------------ Use whole percentages ______________% Delaware Emerging Markets Series ______________% Delaware Growth & Income Series ______________% Delaware High Yield Series* ______________% Delaware REIT Series ______________% Delaware Select Growth Series ______________% Delaware Small Cap Value Series ______________% Delaware Social Awareness Series ______________% Delaware Trend Series ______________% AIM V.I. Capital Appreciation Fund ______________% AIM V.I. Growth Fund ______________% AIM V.I. International Fund ______________% AIM V.I. Value Fund ______________% Alliance Growth Portfolio ______________% Alliance Growth & Income Portfolio ______________% Alliance Premier Growth Portfolio ______________% Alliance Technology Portfolio ______________% American Funds Global Small Cap Fund ______________% American Funds Growth Fund ______________% American Funds Growth-Income Fund ______________% American Funds International Fund ______________% Deutsche VIT Equity 500 Index Fund ______________% Fidelity VIP Equity Income Portfolio ______________% Fidelity VIP Growth Portfolio ______________% Fidelity VIP Overseas Portfolio ______________% Fidelity VIP III Growth Opportunities Portfolio ______________% Franklin Templeton Growth Securities Fund ______________% Franklin Templeton International Securities Fund ______________% Franklin Templeton Mutual Shares Securities Fund ______________% Franklin Templeton Small Cap Securities Fund ______________% Liberty Newport Tiger Fund ______________% Lincoln National Bond Fund* ______________% Lincoln National Money Market Fund* ______________% MFS Emerging Growth Series ______________% MFS Research Series ______________% MFS Total Return Series ______________% MFS Utilities Series ==============% Total (must = 100%) ------------------------------------------------------------------------ Future contributions will not automatically start a new DCA program. Instructions must accompany each DCA contribution. ------------------------------------------------------------------------ Page 2 ------------------------------------------------------------------------------- 5c Cross-Reinvestment or Portfolio Rebalancing ------------------------------------------------------------------------------- To elect either of these options, please complete the Cross-Reinvestment form (28051CP) or the Portfolio Rebalancing form (28887CP). -------------------------------------------------------------------------------- 6 Death Benefit Option -------------------------------------------------------------------------------- [_] I/We hereby elect the 5% Step-Up* death benefit option. I/We understand that if this benefit is not elected, my/our death benefit will be the Enhanced Guaranteed Minimum Death Benefit. * The 5% Step-Up option may only be elected if the Contract Owner, Joint Owner (if applicable), and Annuitant are all under age 80. -------------------------------------------------------------------------------- 7 Automatic Withdrawals -------------------------------------------------------------------------------- Note: Withdrawals exceeding 10% of the greater of total contract value or premium payments per contract year may be subject to contingent deferred sales charges. Withdrawal minimum: $50 per distribution/$300 annually --------------------------------------------------------------------------- [_] Please provide me with automatic withdrawals based on ___% (may be between 1-10%) of the greater or total contract value or premium payments, payable as follows: [_] Monthly [_] Quarterly [_] Semiannually [_] Annually Begin withdrawals in [_][_] [_][_] Month Year --------------------------------------------------------------------------- --------------------------------------------------------------------------- [_] Please provide me with automatic withdrawals of $_________________ [_] Monthly [_] Quarterly [_] Semiannually [_] Annually Begin withdrawals in [_][_] [_][_] Month Year --------------------------------------------------------------------------- Note: If no tax withholding selection is made, federal taxes will be withheld at a rate of 10%. ELECT ONE: [_] Do withhold taxes Amount to be withheld $___________________ OR _________% [_] Do not withhold taxes ELECT ONE: [_] Send check to address of record OR [_] Send check to the following alternate address: [_] Direct deposit For direct deposit into your bank account, the Electronic Fund Transfer Authorization form (27326CP) must be completed and submitted with ______________________________ a voided check or a savings ______________________________ deposit slip. ______________________________ -------------------------------------------------------------------------------- 8 Automatic Bank Draft -------------------------------------------------------------------------------- __________________________________________________________________ Print account holder name(s) EXACTLY as shown on bank records __________________________________________________________________ _______________________________________________________ ATTACH VOIDED CHECK Bank name ABA number ___________________________________________________________________________ Bank street address City State ZIP Automatic bank draft start date: [_][_] [_][_] [_][_] Month Day Year (1-28) _____________________________________________________ $___________________ Checking account number Monthly amount I/We hereby request and authorize you to pay and charge to my/our accounts, checks or electronic fund transfer debits processed by and payable to the order of Lincoln Life, P.O. Box 7866, Fort Wayne, IN 46801-7866, provided there are sufficient collected funds in said account to pay the same upon presentation. It will not be necessary for any officer or employee of Lincoln Life to sign such checks. I/We agree that your rights in respect to each such check shall be the same as if it were a check drawn on you and signed personally by me/us. This authority is to remain in effect until revoked by me/us, and until you actually receive such notice I/we agree that you shall be fully protected in honoring any such check or electronic fund transfer debit. I/We further agree that if any such check or electronic fund transfer debit be dishonored, whether with or without cause and whether intentionally or inadvertently, you shall be under no liability whatsoever even though such dishonor results in the forfeiture of insurance or investment loss to me/us. -------------------------------------------------------------------------------- 9 Telephone/Internet Authorization (Check box if this option is desired.) -------------------------------------------------------------------------------- [_] I/We hereby authorize and direct Lincoln Life to accept instructions via telephone or the Internet from any person who can furnish proper identification to exchange units from subaccount to subaccount, change the allocation of future investments, and/or clarify any unclear or missing administrative information contained on this application at the time of issue. I/We agree to hold harmless and indemnify Lincoln Life and their affiliates and any mutual fund managed by such affiliates and their directors, trustees, officers, employees and agents for any losses arising from such instructions. Page 3 -------------------------------------------------------------------------------- 10 Replacement Will the proposed contract replace any existing annuity or life insurance contract? -------------------------------------------------------------------------------- ELECT ONE: [_] No [_] Yes If yes, complete the 1035 Exchange or Qualified Retirement Account Transfer form. (Attach a state replacement form if required by the state in which the application is signed.) _________________________________________________________________________________________________ Company name _________________________________________________________________________________________________ Plan name Year issued ======================================================================================================
Fraud Warning Residents of all states except Virginia please note: Any person who knowingly, and with intent to defraud any insurance company or other person, files or submits an application or statement of claim containing any materially false or deceptive information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. -------------------------------------------------------------------------------- 11 Signatures -------------------------------------------------------------------------------- All statements made in this application are true to the best of my/our knowledge and belief, and I/we agree to all terms and conditions as shown. I/We acknowledge receipt of current prospectuses for Lincoln ChoicePlus(SM) Bonus and verify my/our understanding that all payments and values provided by the contract, when based on investment experience of the funds in the Series, are variable and not guaranteed as to dollar amount. I/We understand that all payments and values based on the fixed account are subject to a market value adjustment formula that may increase or decrease the value of any transfer, partial surrender, or full surrender from the fixed account made prior to the end of a guaranteed period. Under penalty of perjury, the Contract Owner(s) certifies that the Social Security (or taxpayer identification) number(s) is correct as it appears in this application. ---------------------------------------------------------------------------------------- Signed at (city) State Date [_][_] [_][_] [_][_] Month Day Year ---------------------------------------------------------------------------------------- Signature of Contract Owner Joint Contract Owner (if applicable) ------------------------------------- ------------------------------------------------ Signed at (city) State Date [_][_] [_][_] [_][_] Month Day Year ______________________________________________________________________________________ Signature of Annuitant (Annuitant must sign if Contract Owner is a trust or custodian.)
================================================================================ FINANCIAL ADVISER MUST COMPLETE REVERSE SIDE (PAGE 5) ================================================================================ Page 4 ================================================================================ THE FOLLOWING SECTIONS MUST BE COMPLETED BY THE SECURITIES DEALER OR FINANCIAL ADVISER. Please type or print. -------------------------------------------------------------------------------- 12 Insurance in Force Will the proposed contract replace any existing annuity or life insurance contract? -------------------------------------------------------------------------------- ELECT ONE: [_] No [_] Yes If yes, please list the insurance in force on the life of the proposed Contract Owner(s) and Annuitant(s): (Attach a state replacement form if required by the state in which the application was signed.)
_____________________________________________________________________________________________ $________________ Company name Year issued Amount -------------------------------------------------------------------------------- 13 Additional Remarks -------------------------------------------------------------------------------- _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ -------------------------------------------------------------------------------- 14 Dealer Information -------------------------------------------------------------------------------- Option: [_] 1 [_] 2 [_] 3 Note: Licensing appointment with Lincoln Life is required for this application to be processed. If more than one representative, please indicate names and percentages in Section 13. ___________________________________________________________________________ [_][_][_]-[_][_][_]-[_][_][_][_] Registered representative's name (print as it appears on NASD licensing) Registered representative's telephone number ___________________________________________________________________________ [_][_][_]-[_][_]-[_][_][_][_] Client account number at dealer (if applicable) Registered representative's SSN ________________________________________________________________________________________________________________________________ Dealer's name ________________________________________________________________________________________________________________________________ Branch address City State ZIP ________________________________________________________________________________________________________________________________ Branch number Representative number [_] CHECK IF BROKER CHANGE OF ADDRESS -------------------------------------------------------------------------------- 15 Representative's Signature -------------------------------------------------------------------------------- The representative hereby certifies that he/she witnessed the signature(s) in Section 11 and that all information contained in this application is true to the best of his/her knowledge and belief. ________________________________________________________________________________________________________________________________ Signature =================================================================================================================================== Send completed application -- with a check made payable to Lincoln Life -- to your investment dealer's home office or to: ---------------------- Logo Express Mail: ---------------------- Lincoln Life Lincoln Life P.O. Box 7866 Attention: ChoicePlus Operations Fort Wayne, IN 46801-7866 1300 South Clinton Street Fort Wayne, IN 46802 If you have any questions regarding this application, please call Lincoln Life at 888 868-2583.
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