EX-5.(E) 3 e66869bexv5wxey.txt INITIAL ALLOCATION SCHEDULE EXHIBIT 5(e) [ ] Nationwide Life Insurance Company of America PC 0103 Service and Technology Center, P.O. Box 15750, Wilmington, DE 19850-5750, (800) 688-5177 [ ] Nationwide Life and Annuity Company of America Service and Technology Center, P.O. Box 15750, Wilmington, DE 19850-5750, (800) 688-5177 INITIAL ALLOCATION SCHEDULE OPTIONS PREMIER, SURVIVOR OPTIONS PREMIER, SURVIVOR OPTIONS ELITE To be use in conjunction with application dated__________________________ (Month, Day, Year) Proposed Insured_______________________________________________________________ (First Name, Middle Initial, Last Name) _______________________________________________________________________________ INITIAL ALLOCATION PERCENTAGES (WHOLE PERCENTAGES ONLY)
MONTHLY DOLLAR COST PREMIUMS DEDUCTIONS AVERAGING AIM VARIABLE INSURANCE FUND, INC. AIM V.I. Basic Value Fund - Series I..... _____% _____% _____% AIM V.I. Capital Appreciation Fund - Series I............................ _____% _____% _____% AIM V.I. Capital Development Fund - Series I............................ _____% _____% _____% ALLIANCEBERNSTEIN VARIABLE PRODUCTS SERIES FUND, INC. AllianceBernstein Growth & Income Portfolio - Class A................. _____% _____% _____% AllianceBernstein Small Cap Value Portfolio - Class A................. _____% _____% _____% AMERICAN CENTURY VARIABLE PORTFOLIOS American Century VP Income & Growth Fund - Class I...................... _____% _____% _____% American Century VP Inflation Protection Fund - Class II..................... _____% _____% _____% American Century VP International Fund - Class I............................. _____% _____% _____% American Century VP Ultra(R) Fund - Class I............................. _____% _____% _____% American Century VP Value Fund - Class I. _____% _____% _____% DREYFUS INVESTMENT PORTFOLIOS Small Cap Stock Index Portfolio - Service Shares.............................. _____% _____% _____% DREYFUS STOCK INDEX FUND, INC. Dreyfus Stock Index Fund, Inc. - Initial Shares.............................. _____% _____% _____% DREYFUS VARIABLE INVESTMENT FUND Appreciation Portfolio - Initial Shares.. _____% _____% _____% Developing Leaders Portfolio - Initial Shares.............................. _____% _____% _____% FEDERATED INSURANCE SERIES Federated American Leaders Fund II - Primary Shares...................... _____% _____% _____% Federated Capital Appreciation Fund II - Primary Shares...................... _____% _____% _____% Federated Quality Bond Fund II - Primary Shares.............................. _____% _____% _____% FIDELITY VARIABLE INSURANCE PRODUCTS VIP Contrafund(R) Portfolio - Initial Class............................... _____% _____% _____% VIP Equity-Income Portfolio - Initial Class............................... _____% _____% _____% VIP Growth Portfolio - Initial Class..... _____% _____% _____% VIP Investment Grade Bond Portfolio - Initial Class....................... _____% _____% _____% VIP Mid Cap Portfolio - Service Class.... _____% _____% _____% VIP Overseas Portfolio - Initial Class... _____% _____% _____% VIP Value Strategies Portfolio - Service Class............................... _____% _____% _____% FRANKLIN TEMPLETON VARIABLE INSURANCE PRODUCTS TRUST Franklin Rising Dividends Securities Fund - Class I...................... _____% _____% _____% Franklin Small Cap Value Securities Fund - Class I...................... _____% _____% _____% Templeton Foreign Securities Fund - Class I............................. _____% _____% _____% GARTMORE VARIABLE INSURANCE TRUST Comstock GVIT Value Fund - Class IV...... _____% _____% _____% Dreyfus GVIT International Value Fund - Class IV............................ _____% _____% _____% Dreyfus GVIT Mid Cap Index Fund - Class I............................. _____% _____% _____% Federated GVIT High Income Bond Fund - Class I............................. _____% _____% _____% Gartmore GVIT Emerging Markets Fund - Class I............................. _____% _____% _____% Gartmore GVIT Global Financial Services Fund - Class I...................... _____% _____% _____% Gartmore GVIT Global Health Sciences Fund - Class I...................... _____% _____% _____% Gartmore GVIT Global Technology and Communications Fund - Class I....... _____% _____% _____% Gartmore GVIT Global Utilities Fund - Class I............................. _____% _____% _____% Gartmore GVIT Government Bond Fund - Class IV............................ _____% _____% _____% Gartmore GVIT Investor Destinations Aggressive Fund..................... _____% _____% _____% Gartmore GVIT Investor Destinations Conservative Fund................... _____% _____% _____% Gartmore GVIT Investor Destinations Moderate Fund....................... _____% _____% _____% Gartmore GVIT Investor Destinations Moderately Aggressive Fund.......... _____% _____% _____% Gartmore GVIT Investor Destinations Moderately Conservative Fund........ _____% _____% _____% Gartmore GVIT Mid Cap Growth Fund - Class IV............................ _____% _____% _____% Gartmore GVIT Money Market Fund - Class IV............................ _____% _____% _____% Gartmore GVIT Nationwide(R) Fund - Class IV............................ _____% _____% _____% Gartmore GVIT US Growth Leaders Fund - Class I............................. _____% _____% _____% GVIT Small Cap Growth Fund - Class I..... _____% _____% _____% GVIT Small Cap Value Fund - Class IV..... _____% _____% _____% GVIT Small Company Fund - Class IV....... _____% _____% _____% Van Kampen GVIT Multi Sector Bond Fund - Class I............................. _____% _____% _____% JANUS ASPEN SERIES Balanced Portfolio - Service Shares...... _____% _____% _____% Capital Appreciation Portfolio - Service Shares...................... _____% _____% _____% International Growth Portfolio - Service Shares...................... _____% _____% _____% Risk-Managed Large Cap Core Portfolio - Service Shares...................... _____% _____% _____% MFS(R) VARIABLE INSURANCE TRUST MFS(R) Investors Growth Stock Series - Initial Class....................... _____% _____% _____% MFS(R) Value Series - Initial Class...... _____% _____% _____% NEUBERGER BERMAN ADVISERS MANAGEMENT TRUST AMT Fasciano Portfolio - Class S......... _____% _____% _____% AMT Limited Maturity Bond Portfolio - Class I............................. _____% _____% _____% AMT Mid Cap Growth Portfolio - Class I... _____% _____% _____% AMT Socially Responsive Portfolio - Class I............................. _____% _____% _____% OPPENHEIMER VARIABLE ACCOUNT FUNDS Oppenheimer Capital Appreciation Fund/VA - Initial Class............. _____% _____% _____% Oppenheimer Global Securities Fund/VA - Initial Class....................... _____% _____% _____% Oppenheimer High Income Fund/VA - Initial Class....................... _____% _____% _____% Oppenheimer Main Street(R) Fund/VA - Initial Class....................... _____% _____% _____% Oppenheimer Main Street(R) Small Cap Fund/VA - Initial Class............. _____% _____% _____% PUTNAM VARIABLE TRUST Putnam VT Growth & Income Fund - Class 1B............................ _____% _____% _____% Putnam VT International Equity Fund - Class 1B............................ _____% _____% _____% Putnam VT Voyager Fund - Class 1B........ _____% _____% _____% VAN KAMPEN - THE UNIVERSAL INSTITUTIONAL FUNDS, INC. Core Plus Fixed Income Portfolio - Class I............................. _____% _____% _____% Emerging Markets Debt Portfolio - Class I............................. _____% _____% _____% U.S. Real Estate Portfolio - Class I..... _____% _____% _____% GUARANTEED ACCOUNT....................... _____% _____% _____% _________________________________________ _____% _____% _____% TOTAL 100% 100% 100%
_______________________________________________________________________________ Signed at (City and State)_________________ On (Date)_____________________ (Month, Day, Year) Owner Name (please print)__________________ Owner Signature_______________ Owner Name (please print)__________________ Owner Signature_______________ A64 1.03 (Rev. 5.03)