EX-5 3 ex5.htm VARIABLE ANNUITY APPLICATION ex5.htm
 
 
 
 

 
 
 
 
 
 

 
 
 
 
 

 
 
 
 
 

 
 
 
 
 
 

 
 
 
 
 
 
 
 

 
 
 
 
 
 
 

 

 
CONTRACT SPECIFICATIONS PAGE
CONTRACT INFORMATION

Parties to the Contract
Date of Birth
Additional Issuing Information
Contract Owner:  [John Q. Doe]
[January 1, 1956]
Contract Number:  [01-000000000]
Joint Owner:  [Jane M. Doe]
[December 1, 1961]
Date of Issue:  [May 14, 2010]
Annuitant:  [John Q. Doe]
[January 1, 1956]
Contract Type:  [Non-qualified]
Co-Annuitant:  [N/A]
[N/A]
 
Initial Purchase Payment: [$5,000]
   
Contingent Owner: [N/A]
[N/A]
 
Annuity Commencement Date: [January 1, 2046]
   
Contingent Annuitant: [N/A]
[N/A]
 
 
Minimum Requirements
Subsequent Purchase Payments: $500
Minimum Annuity Payment Amount: $100
Minimum Contract Value Required for Annuitization: $2,000

STANDARD DEATH BENEFIT
[  X  ]           Standard Death Benefit (Return of Premium with Spousal Protection, less adjustments for amounts Surrendered)

SUMMARY OF CONTRACT EXPENSES

 
Base Contract Variable Accounts Charges:
 
    Mortality & Expense Risk Charge
1.55%* (during the first eight years of the Contract decreasing to
 
1.30% *after the first eight years of the Contract are complete.)
    Administrative Charge
0.20%
Contract Maintenance Charge:
$30**

Contingent Deferred Sales Charge Table:
Completed Years Measured
                 
From Date of the Purchase Payment:
0
1
2
3
4
5
6
7
8 & Thereafter
CDSC Percentage***:
8%
7%
6%
5%
4%
3%
2%
1%
0%
 
* The base Variable Account Charge noted above does not include charges associated with any optional features you have elected.  These charges are added to the base Variable Account Charge.  Remember, charges related to the Lifetime Income Rider (including the election of the Spousal Continuation Benefit, if elected) are assessed on the value of the Income Benefit Base and are only assessed once a year.
 
** The Contract Maintenance Charge is waived for the life of the contract if the Contract Value reaches $50,000 on any Contract Anniversary.
 
*** The CDSC Percentage changes to the next year's CDSC Percentage on the day before the Purchase Payment year is completed.

OPTIONS ELECTED
Added Charge
Death Benefit Options
One-Year Enhanced Death Benefit with Spousal Protection Option
0.20%
[  X ]
One-Month Enhanced Death Benefit with Spousal Protection Option
0.35%
[      ]
Combination Enhanced Death Benefit (Greater of 1 Year Anniversary or 5% Interest) with Spousal Protection Option
0.45%
[      ]
 
Other Options
Beneficiary Protector II
0.35%
[      ]
The Nationwide Lifetime Income Rider ® MX (L Inc MX)
[1.00-1.50] %
[      ]
L.Inc MX with Spousal Continuation
[1.30-1.80] %
[      ]

Notes Regarding Additional Charges: For the Death Benefit Options listed above, the additional charge is listed as an annual charge added to the base Variable Account Charge but is deducted from the Variable Account on a daily basis.  The charge for the Beneficiary Protector II option is structured in the same manner, but also is applied to the rates credited to any amounts allocated to the Fixed Account, if applicable, resulting in a corresponding decrease to the interest credited.  The L Inc MX Rider, and the Spousal Continuation Benefit, assesses the charge from the Variable Account once each year based on the value of the Income Benefit Base (see the Rider for details).  The Spousal Continuation Benefit is only available in conjunction with the L Inc MX Rider.  An "X" next to the charge denotes the option has been elected.

VAB-0136AO (Standard) (5/2010)