EX-99.B(5)(C) 3 a2176898zex-99_b5c.txt EX-99.B(5)(C) [Lincoln Financial Group(R) LOGO] Exhibit 99.B(5) APPLICATION FOR INDIVIDUAL DEFERRED ANNUITY The Lincoln National Life Insurance Company 1300 South Clinton Street Fort Wayne IN 46802 Phone 800-4LINCOLN (800-454-6265) (C)2004 Lincoln Financial Group IS THE MARKETING NAME FOR LINCOLN NATIONAL CORPORATION AND ITS AFFILIATES. Form 28316 02/99 [Lincoln Financial Group(R) LOGO] APPLICATION FOR INDIVIDUAL DEFERRED ANNUITY The Lincoln National Life Insurance Company 1300 South Clinton Street Fort Wayne IN 46802 Phone 800-4LINCOLN (800-454-6265) www.LFG.com Complete this form to apply for a MULTI-FUND(R) or INDIVIDUAL FIXED ANNUITY. Any alterations to this application must be initialed by the annuitant and contract owner (if other than annuitant). 1 ANNUITANT Last First Middle Initial Name (print) _______________________________________________________________________________________________________________________ Address ____________________________________________________________________________________________________________________________ City _____________________________________________________________________ State _______________ ZIP ____________________-__________ Social Security no. __________-__________-__________ Date of birth __________/__________/__________ |_| Male |_| Female month day year Home phone no. __________-__________-__________ Business phone no. __________-__________-__________ |_| Married |_| Not married 2 EMPLOYER/REMITTER Is this contract employer sponsored? (IF "YES", YOU MUST COMPLETE THE FOLLOWING) |_| Yes |_| No Remitter name _________________________________________________________________________ Remitter no. ____________-__________________ 3 SUITABILITY COMPLETE THIS INFORMATION FOR THE CONTRACT OWNER. IF THE CONTRACT OWNER IS AN EMPLOYER; COMPLETE FOR THE ANNUITANT. Client's investment objective for this contract is: (SELECT ONE) |_| Preservation of Capital |_| Income |_| Growth & Income |_| Long Term Growth |_| Maximum Capital Appreciation |_| Asset Allocation Fund of Funds |_| Flexible Allocation Occupation _________________________________________________________________________________________________________________________ Number of dependents ___________ Total family income $____________________________ Estimated net worth $____________________________ 4 CONTRACT OWNER COMPLETE ONLY IF THE CONTRACT IS NONQUALIFIED AND THE CONTRACTOWNER IS NOT THE ANNUITANT. Last First Middle Initial Name or trust's name* ______________________________________________________________________________________________________________ Address ____________________________________________________________________________________________________________________________ City _____________________________________________________________________ State _______________ ZIP ____________________-__________ Home phone no. __________-__________-__________ Business phone no. __________-__________-__________ |_| Male |_| Female Social Security no. __________-__________-__________ Date of birth __________/__________/__________ |_| Married |_| Not married month day year Executor/Trustee name* _____________________________________________________________ Date of trust* __________/__________/__________ * THIS INFORMATION IS REQUIRED FOR TRUSTS. month day year |_| Joint contract owner |_| Contingent contract owner Last First Middle Initial Name _______________________________________________________________________________________________________________________________ Social Security no. __________-__________-__________ Date of birth __________/__________/__________ |_| Male |_| Female month day year 5 BENEFICIARY DESIGNATION IF ADDITIONAL SPACE IS NEEDED, PROVIDE COMPLETE INFORMATION IN THE SPECIAL INSTRUCTIONS SECTION. Primary's name ________________________________________________________________ Social Security no. __________-__________-__________ Date of birth __________/__________/__________ Relationship: |_| Spouse |_| Child |_| Parent |_| Other ___________________ ________% month day year |_| Primary |_| Secondary Name __________________________________________________________________________ Social Security no. __________-__________-__________ Date of birth __________/__________/__________ Relationship: |_| Spouse |_| Child |_| Parent |_| Other ___________________ ________% month day year |_| Primary |_| Secondary Name __________________________________________________________________________ Social Security no. __________-__________-__________ Date of birth __________/__________/__________ Relationship: |_| Spouse |_| Child |_| Parent |_| Other ___________________ ________% month day year LINCOLN FINANCIAL GROUP IS THE MARKETING NAME FOR LINCOLN NATIONAL CORPORATION AND ITS AFFILIATES.
Form 28316 2/99 1 6 CONTRACT Product: SELECT ONE: |_| Multi-Fund(R) |_| Individual Fixed Annuity Market: |_| 403(b) |_| 403(a)/401(a) |_| 401(k) SELECT ONE: |_| Nonqualified |_| Roth IRA |_| Ordinary IRA |_| SEP |_| SARSEP |_| 457(b) Government/Non-Profit |_| 457(f) Executive Benefit 7 CONTRIBUTION Lump sum $_____________________________________________________________ Tax year to apply IRA contribution __________________ PERIODIC PRODUCTS - COMPLETE THE FOLLOWING INFORMATION. 403(a) NON- ORDINARY/ 401(a) SOURCE QUALIFIED ROTH IRA SEP SARSEP 403(b) 401(k) 457 FREQUENCY* ---------------------------------------------------------------------------------- Employee Deferred Compensation/ Employee Mandatory Deferral F $ Employee Salary Reduction Elective G $ $ $ Deferrals Employee Deductible Contribution H $ $ Employee non-deductible voluntary I $ $ Roth (rollover of after tax money) S $ $ Employer Contributions A $ $ Employer Discretionary Contributions C $ $ Employer Matching D $ $ $ *FREQUENCIES: (A) ANNUAL (S/A) SEMI-ANNUAL (Q) QUARTERLY (M) MONTHLY (S/M) SEMI-MONTHLY (B/W) BI-WEEKLY (W) WEEKLY Indicate the months in which contributions will NOT be sent (IF APPLICABLE)__________________________________________________ 8 ALLOCATION OF CONTRIBUTIONS COMPLETE THIS SECTION FOR MULTI-FUND(R) CONTRACTS ONLY. Entries must be in whole percentages and total 100%. PRESERVATION OF CAPITAL LONG TERM GROWTH MAXIMUM CAPITAL APPRECIATION __________% Fixed Account __________% American Funds Global Growth __________% AllianceBernstein Global __________% Lincoln VIP Money Market __________% American Funds Growth Technology INCOME __________% American Funds International __________% Baron Capital Asset __________% Delaware VIP Diversified Income __________% Delaware VIP Small Cap Value __________% Delaware VIP Trend __________% Delaware VIP High Yield __________% DWS Equity 500 Index VIP __________% DWS Small Cap Index VIP __________% Lincoln VIP Bond __________% Fidelity VIP Contrafund __________% Lincoln VIP Aggressive Growth GROWTH & INCOME __________% Fidelity VIP Growth __________% Neuberger Berman AMT __________% AllianceBernstein __________% Lincoln VIP Capital Mid-Cap Growth Growth & Income Appreciation ASSET ALLOCATION FUND OF FUNDS __________% American Funds Growth-Income __________% Lincoln VIP Growth and Income __________% Lincoln VIP Aggressive Profile __________% Delaware VIP Value __________% Lincoln VIP International __________% Lincoln VIP Conservative Profile __________% Delaware VIP REIT __________% Lincoln VIP Social Awareness __________% Lincoln VIP Moderate Profile __________% Lincoln VIP Equity-Income __________% Lincoln VIP Special __________% Lincoln VIP Moderately __________% Lincoln VIP Global Asset Opportunities Aggressive Profile Allocation __________% MFS VIT Utilities __________% Lincoln VIP Managed 9 MULTI-FUND(R) TELEPHONE AUTHORIZATION AGREEMENT You, the contract owner, authorize and direct Lincoln Life to accept telephone instructions from any person who can furnish proper identification to shift units from any subaccount to any other subaccount and/or to change the allocation of future contributions. You also agree that Lincoln Life is not responsible for any loss arising from any telephone exchange or change in allocation of future contributions. |_| Yes |_| No
2 10 REPLACEMENT Will the proposed contract replace any existing annuity or life insurance? |_| Yes |_| No SUBMIT APPLICABLE REPLACEMENT FORMS AND COMPLETE THE FOLLOWING: Company's name ________________________________________________________________ Contract no. _____________________________________ Type of existing contract: |_| Life insurance |_| Annuity Year issued _________________________ Type of replacement: |_| Full transfer |_| Partial transfer |_| Reduced/paid up Company's name ________________________________________________________________ Contract no. _____________________________________ Type of existing contract: |_| Life insurance |_| Annuity Year issued _________________________ Type of replacement: |_| Full transfer |_| Partial transfer |_| Reduced/paid up 11 SPECIAL INSTRUCTIONS 12 REQUIRED NOTICE RESIDENTS OF MARYLAND, OREGON AND VERMONT 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 may subject such person to criminal and civil penalties. RESIDENTS OF ALL OTHER STATES EXCEPT VIRGINIA AND WASHINGTON, 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. 13 AGREEMENT AND SIGNATURES YOU AGREE THAT: All statements made in this application are true to the best of your knowledge and belief, and you agree to all terms and conditions as shown. You further agree that this application is part of the annuity contract. IF YOU ARE APPLYING FOR A MULTI-FUND(R) ANNUITY, YOU ACKNOWLEDGE RECEIPT OF A CURRENT MULTI-FUND(R) PROSPECTUSES AND VERIFY YOUR UNDERSTANDING THAT ALL PAYMENTS AND VALUES PROVIDED BY THE CONTRACT, WHEN BASED ON INVESTMENT EXPERIENCE OF THE SUBACCOUNT(S), ARE VARIABLE AND NOT GUARANTEED AS TO DOLLAR AMOUNT. 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. THE FOLLOWING STATEMENT APPLIES TO RESIDENTS OF AL, AK, AR, DE, ID, KY, LA, ME, MI, MO, MT, NV, SD, WA AND WY: Acceptance of the annuity contract will mean acceptance of all of its terms and ratification of any changes noted on the "Home Office Corrections and Additions" endorsement to the application. Changes to the items which may affect the benefits applied for must be agreed to by you in writing. THE FOLLOWING STATEMENT APPLIES TO RESIDENTS OF ALL STATES (EXCEPT MD, NY AND WV): Acceptance of the annuity contract will mean acceptance of all of its terms and ratification of any changes noted on the "Home Office Corrections and Additions" endorsement to the application. Funding allocations must be designated by you in writing. THE FOLLOWING STATEMENT APPLIES ONLY TO 403(b) CONTRACTS - You agree to abide by the distribution rules as described in IRC section 403(b)(11). This code section prohibits the distribution of salary reduction elective deferrals made after 12/31/88 and earnings from 403(b) contracts except in the following events: attainment of age 59 1/2; separation from service; death of the annuitant; disability of the annuitant as defined in IRC section 72(m)(7); or financial hardship. If claiming financial hardship, you may not withdraw earnings on elective deferrals. - If you are not 100% vested in the employer contributions and earnings attributable to employer contributions held in the contract and you separate from service, the non-vested account balance will be forfeited. Signed at ------------------------------------------------------------------------------------------------------------------------------------ City State Annuitant's signature X Date / / ------------------------------------------------------------------------------------ ---------- ---------- -------------------- Contract owner's signature (if other than annuitant) X Date / / ------------------------------------------------------------------------------------ ---------- ---------- -------------------- FOR ERISA PLANS ONLY: If the annuitant is married and the primary beneficiary is someone other than the spouse, the spouse must sign below. Their signature must be witnessed by the plan administrator or a Notary Public. Spouse's signature X ------------------------------------------------------------------------------------------------------------------------------------ Witness' signature X Notary Public commission expires / / ----------------------------------------------------------- -------- ---------- ------------------- WITNESSED BY PLAN ADMINISTRATOR OR A NOTARY PUBLIC.
3 14 AGENT'S REPORT Do you have any knowledge or reason to believe that the proposed annuity contract will replace any existing annuity or life insurance contract, including any Lincoln Life contracts? |_| Yes |_| No If "yes," provide details ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ Servicing agent's name (PRINT OR TYPE) _____________________________________________________________________________________________ Phone no. ______________-____________-______________ Social Security no. _______________-_____________-________________ SA code ____________________________ PC code ______________________ Split _________________________ Mail code _________________ Agent's name (PRINT OR TYPE) _______________________________________________________________________________________________________ Phone no. ______________-____________-______________ Social Security no. _______________-_____________-________________ SA code ____________________________ PC code ______________________ Split _________________________ Agent's name (PRINT OR TYPE) _______________________________________________________________________________________________________ Phone no. ______________-____________-______________ Social Security no. _______________-_____________-________________ SA code ____________________________ PC code ______________________ Split _________________________ Agent's name (PRINT OR TYPE) _______________________________________________________________________________________________________ Phone no. ______________-____________-______________ Social Security no. _______________-_____________-________________ SA code ____________________________ PC code ______________________ Split _________________________ As agent, you certify that: - You have truly and accurately recorded on this application the information supplied by the annuitant and/or contract owner; - You have reviewed the investment objectives and financial needs of the applicant and believe that this product is suitable for addressing those objectives and needs. Agent's signature Date / / ------------------------------------------------------------------------------ ------------- ------------ --------------------- ------------------------------------------------------------------------------------------------------------------------------------ Send completed application to: By Express Mail to: Lincoln Financial Group Lincoln Financial Group PO Box 2340 1300 South Clinton Street Fort Wayne IN 46801-2340 Fort Wayne IN 46802-3508 If you have any questions regarding this application, please call Lincoln Financial Group at 800 454-6265.
4 [Lincoln Financial Group(R) LOGO] CUSTOMER IDENTIFICATION VERIFICATION FORM IMPORTANT INFORMATION ABOUT NEW CUSTOMER IDENTIFICATION PROCEDURES Policy/Contract No.: ___________________ The USA PATRIOT Act requires all financial institutions, including The Lincoln National Life Insurance Company, to obtain, verify, and maintain information that identifies each person who opens a new account with the Company. To meet this federal obligation we will ask for your name, address, date of birth or articles of incorporation or similar documents and other information, including a driver's license or other government issued identification that will allow us to verify your identity. This process may include the use of third party sources to verify the information provided. For policies or contracts owned by a Trust, new customer identification procedures will require the Company to obtain a copy of a Trust instrument. Any Trust instrument will be retained solely for purposes of customer identification as required by law and the Company accepts no responsibility for the enforcement or administration of any of the terms thereof. Information required for each OWNER. Use additional forms if necessary. OWNER JOINT OWNER Name: __________________________________________________________ Name: ___________________________________________________________ Social Security No./Tax ID#: ___________________________________ Social Security No./Tax ID#: ____________________________________ Date of Birth: _________________________________________________ Date of Birth: __________________________________________________ Address: (SELECT ONE, NO PO BOX) Address: (SELECT ONE, NO PO BOX) Residential: ________________________________________________ Residential: _________________________________________________ (Street Address) (Street Address) ________________________________________________ _________________________________________________ (City, State, Zip Code) (City, State, Zip Code) Business: ___________________________________________________ Business: ____________________________________________________ (Street Address) (Street Address) ___________________________________________________ ____________________________________________________ (City, State, Zip Code) (City, State, Zip Code) Check one form of ID: Check one form of ID: Individual Owner Non-individual Owner Individual Owner Non-individual Owner |_| Driver's License |_| Certified Articles of |_| Driver's License |_| Certified Articles of |_| Passport Incorporation |_| Passport Incorporation |_| Social Security Card |_| Partnership Agreement |_| Social Security Card |_| Partnership Agreement |_| Alien Card |_| Trust Document |_| Alien Card |_| Trust Document |_| Military ID |_| Military ID |_| Official Birth Certificate |_| Official Birth Certificate (not a copy) (not a copy) ________________________________________________________________ _________________________________________________________________ ID Number State/Country of Issuance ID Number State/Country of Issuance ________________________________________________________________ _________________________________________________________________ Identification Expiration Date Identification Expiration Date The Licensed Representative signed below certifies that: I personally met with the proposed Owner(s), reviewed the government issued identification described in the attached documentation and verified, to the best of my knowledge, that it accurately reflects the identity of the proposed Owner(s). ________________________________________________________________ _________________________________________________________________ Licensed Representative Name Licensed Representative Signature LINCOLN FINANCIAL GROUP IS THE MARKETING NAME FOR LINCOLN NATIONAL CORPORATION AND ITS AFFILIATES.
FORM 33009 (01/06)