EX-99.5.B 11 dex995b.txt CHOICEPLUS II BONUS APPLICATION ========================= [NEW LOGO] Lincoln ChoicePlus II Bonus(sm) The Lincoln National Life Variable Annuity Application Insurance Company Fort Wayne, Indiana ========================= Instructions: Please type or print. ANY ALTERATIONS TO THIS APPLICATION MUST BE INITIALED BY THE CONTRACT OWNER. 1a Contract Owner Maximum age of Contract Owner is 85. 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* *This information is required for trusts.
1b Joint Contract Owner Maximum age of Joint Contract Owner is 85. Social Security number [_][_][_]-[_][_]-[_][_][_][_] __________________________________________________________ Full legal name Date of birth [_][_] [_][_] [_][_] [_] Male [_] Female 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) Maximum age of Annuitant is 85. Social Security number [_][_][_]-[_][_][_]-[_][_][_][_] __________________________________________________________ Full legal name Date of birth [_][_] [_][_] [_][_] [_] Male [_] Female Month Day Year __________________________________________________________ Street Address Home telephone number [_][_][_] [_][_][_]-[_][_][_][_] __________________________________________________________ City State ZIP
2b Contingent Annuitant Maximum age of Contingent Annuitant is 85. Social Security number [_][_][_]-[_][_]-[_][_][_][_] __________________________________________________________ Full legal name
3 Beneficiary(ies) Of Contract Owner (List additional beneficiaries on separate sheet. If listing children, use full legal names.) % ---------------------------------------------------------- ---------------------------------- ----------------------- -------- Full legal name or trust name* [_] Primary [_] Contingent Relationship to Contract Owner SSN/TIN % ---------------------------------------------------------- ---------------------------------- ----------------------- -------- Full legal name or trust name* [_] Primary [_] Contingent Relationship to Contract Owner SSN/TIN % ---------------------------------------------------------- ---------------------------------- ----------------------- -------- Full legal name or trust name* [_] Primary [_] Contingent Relationship to Contract Owner SSN/TIN __________________________________________________________ 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 II(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 Page 1 5a Allocation (This section must be completed.) Initial minimums: $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. ----------------------------------------------------------------------------- Please allocate my contribution of: $_____________________ OR $_________________________ Initial contribution Approximate amount from previous carrier ----------------------------------------------------------------------------- INTO THE FUND(S) BELOW /downward pointing arrow/ Use whole percentages ----------------------------------------------------------------------------- % Delaware Premium Growth and Income Series --------------- % Delaware Premium U.S. Growth Series --------------- % Delaware Premium REIT Series --------------- % Delaware Premium Small Cap Value Series --------------- % Delaware Premium Trend Series --------------- % Delaware Premium Social Awareness Series --------------- % Delaware Premium High Yield Series --------------- % AIM Growth Fund --------------- % AIM International Fund --------------- % AIM Value Fund --------------- % Alliance Capital Growth and Income Portfolio --------------- % Alliance Capital Premier Growth Portfolio --------------- % Alliance Capital Technology Portfolio --------------- % Alliance Capital Small Cap Value Portfolio --------------- % AFIS Global Small Capitalization Fund --------------- % AFIS Growth Fund --------------- % AFIS Growth-Income Fund --------------- % AFIS International Fund --------------- % Deutsche Asset Equity 500 Index --------------- % Deutsche Asset EAFE Equity Index --------------- % Deutsche Asset Small Cap Value Portfolio --------------- % Fidelity VIP Equity Income Portfolio --------------- % Fidelity VIP Growth Portfolio --------------- % Fidelity VIP Contrafund Portfolio --------------- % Fidelity VIP Overseas Portfolio --------------- % Franklin Templeton Growth Securities Fund --------------- % Franklin Templeton Small Cap Fund --------------- % Janus Worldwide Growth Portfolio --------------- % Janus Balanced Portfolio --------------- % Janus Aggressive Growth Portfolio --------------- % Lincoln National Aggressive Growth Fund --------------- % Lincoln National Bond Fund --------------- % Lincoln National Capital Appreciation Fund --------------- % Lincoln National Global Asset Allocation Fund --------------- % Lincoln National International Fund --------------- % Lincoln National Money Market Fund --------------- % Lincoln National Social Awareness Fund --------------- % MFS Emerging Growth Series --------------- % MFS Capital Opportunities Series --------------- % MFS Total Return Series -------------- % MFS Utilities Series -------------- % Neuberger Berman Regency Portfolio --------------- % Neuberger Berman Mid-Cap Portfolio --------------- % Putnam Growth & Income Fund --------------- % Putnam Health Sciences Fund --------------- 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): [_] DCA Fixed Account (Only available for 12 months or less.) [_] Delaware Premium High Yield Series *The DCA holding account [_] Lincoln National Money Market and the DCA fund elected [_] Lincoln National Bond Fund cannot be the same. -------------------------------------------------------------------------------- INTO THE FUND(S) BELOW /downward pointing arrow/ Use whole percentages -------------------------------------------------------------------------------- % Delaware Premium Growth and Income Series ---------------- % Delaware Premium U.S. Growth Series ---------------- % Delaware Premium REIT Series ---------------- % Delaware Premium Small Cap Value Series ---------------- % Delaware Premium Trend Series ---------------- % Delaware Premium Social Awareness Series ---------------- % Delaware Premium High Yield Series ---------------- % AIM Growth Fund ---------------- % AIM International Fund ---------------- % AIM Value Fund ---------------- % Alliance Capital Growth and Income Portfolio ---------------- % Alliance Capital Premier Growth Portfolio ---------------- % Alliance Capital Technology Portfolio ---------------- % Alliance Capital Small Cap Value Portfolio ---------------- % AFIS Global Small Capitalization Fund ---------------- % AFIS Growth Fund ---------------- % AFIS Growth-Income Fund ---------------- % AFIS International Fund ---------------- % Deutsche Asset Equity 500 Index ---------------- % Deutsche Asset EAFE Equity Index ---------------- % Deutsche Asset Small Cap Value Portfolio ---------------- % Fidelity VIP Equity Income Portfolio ---------------- % Fidelity VIP Growth Portfolio ---------------- % Fidelity VIP Contrafund Portfolio ---------------- % Fidelity VIP Overseas Portfolio ---------------- % Franklin Templeton Growth Securities Fund ---------------- % Franklin Templeton Small Cap Fund ---------------- % Janus Worldwide Growth Portfolio ---------------- % Janus Balanced Portfolio ---------------- % Janus Aggressive Growth Portfolio ---------------- % Lincoln National Aggressive Growth Fund ---------------- % Lincoln National Bond Fund ---------------- % Lincoln National Capital Appreciation Fund ---------------- % Lincoln National Global Asset Allocation Fund ---------------- % Lincoln National International Fund ---------------- % Lincoln National Money Market Fund ---------------- % Lincoln National Social Awareness Fund ---------------- % MFS Emerging Growth Series ---------------- % MFS Capital Opportunities Series ---------------- % MFS Total Return Series ---------------- % MFS Utilities Series ---------------- % Neuberger Berman Regency Portfolio ---------------- % Neuberger Berman Mid-Cap Portfolio ---------------- % Putnam Growth & Income Fund ---------------- % Putnam Health Sciences Fund ---------------- % 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 (28051CP2) or the Portfolio Rebalancing form (28887CP2). 6 Death Benefit Option Select one: (If no benefit is specified, the default Death Benefit will be the Enhanced Guaranteed Minimum Death Benefit) [_] I/We hereby elect the 5% Step-Up/1/ Death Benefit option. [_] I/We hereby elect the Estate Enhancement Benefit/2/ rider which includes the Enhanced Guaranteed Minimum Death Benefit. [_] I/We hereby elect the Estate Enhancement Benefit/2/ rider which includes the 5% Step-Up Death Benefit option. /1/ The 5% Step-Up option may only be elected if the Contract Owner, Joint Owner (if applicable), and Annuitant are all under age 80. /2/ The Estate Enhancement Benefit rider may only be elected if the contract is nonqualified and if the Contract Owner, Joint Owner (if applicable), and Annuitant are all under age 76. 7 Automatic Withdrawal 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 [_] Please provide me with automatic withdrawals of ________% (may be between 1-10%) of the greater of $ ________________________________ total contract value or premium, payable as follows: OR [_] Monthly [_] Quarterly [_] Semiannually [_] Annually [_] Monthly [_] Quarterly [_] Semiannually [_] Annually Begin withdrawals in [__|__] [__|__] Begin withdrawals in [__|__] [__|__] Month Year Month Year --------------------------------------------------------- ---------------------------------------------------------
Note: If no tax withholding selection is made, federal taxes will be withheld at a rate of 10%. Additional state tax withholding may be required depending on state of residency. ELECT ONE: [_] Do withhold taxes Amount to be withheld ________ (must be at least 10%) [_] Do not withhold taxes ELECT ONE: [_] Direct deposit [_] Checking (Attach a "voided" check) [_] Savings (Attach a deposit slip) I/We authorize Lincoln Life to deposit payments to the account and financial institution identified below. Lincoln Life is also authorized to initiate corrections, if necessary, to any amounts credited or debited to my/our account in error. This authorization will remain in effect until my/our funds are depleted or I/we notify Lincoln Life of a change in sufficient time to act. This authorization requires the financial institution to be a member of the National Automated Clearing House Association (NACHA). __________________________________________________________________________________________________________________ Bank name Bank telephone number [_] Send check to address of record [_] Send check to following alternate address: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________
8 Automatic Bank Draft ________________________________________________________________ _____________________________________________________________ Print account holder name(s) EXACTLY as shown on bank records __________________________________________________________________________________________________________________________________ Bank name Bank telephone number ____________________________________________________________________________________________________$_____________________________ ABA number Checking account number Monthly amount Automatic bank draft start date: [__|__] [__|__] [__|__] ATTACH VOIDED CHECK Month Day (1-28) Year
I/We hereby authorize Lincoln Life to initiate debit entries to my/our account and financial institution indicated above and to debit the same to such account for payments into an annuity contract. This authorization is to remain in full force and effect until Lincoln Life has received written notification from me/us of its termination in such time and manner as to afford Lincoln Life and the financial institution a reasonable opportunity to act on it. Page 3 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 its affiliates and any mutual fund managed by such affiliates and their directors, trustees, officers, employees and agents for any losses arising from such instructions. 10 Replacement Does the applicant have any existing life policies or annuity contracts? [_] Yes [_] No Will the proposed contract replace any existing annuity or life insurance? [_] Yes [_] No (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 II Bonus(SM) 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 an interest 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 PAGE 5. ================================================================================ Page 4 ------------------------------------------------------------------------------------------------------------------------------------ THE FOLLOWING SECTIONS MUST BE COMPLETED BY THE FINANCIAL ADVISER OR SECURITIES DEALER. 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 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. [_] 1 [_] 2 [_] 3 OR [_] Income4Life(SM) Solution--complete Form 30350CP (nonqualified) or Form 30350Q-CP (qualified) _____________________________________________________________________________ [_][_][_] [_][_][_]-[_][_][_][_] 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 Registered representative number [_] CHECK IF BROKER CHANGE OF ADDRESS 15 Registered 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. The representative also certifies that he/she has used only The Lincoln National Life Insurance Company approved sales materials in conjunction with this sale; and copies of all sales materials were left with the applicant(s). Any electronically presented sales material shall be provided in printed form to the applicant no later than at the time of the policy or the contract delivery. _______________________________________________________________________________________________________________________________ Signature Send completed application--with a check made payable to Lincoln Life--to your investment dealer's [LOGO OF LINCOLN CHOICE PLUS] home office or to: 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 800 826-6848.
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