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EXHIBIT 1.10(c)
[LOGO] [10 North Martingale Road
SUPPLEMENTAL APPLICATION Schaumburg, Illinois 60173-2268
Required for all Variable Products (847) 466-8000]
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FINANCIAL INFORMATION
APPLICANT/OWNER
Date of
Name: Birth: _____/_____/_____
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Social Security No.
or Taxpayer I.D. No.:
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Estimated Net Worth:
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Estimated Current Annual Household Income:
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Number of Dependents:
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Estimated Federal Income Tax bracket: / /15% / / 28% / / 31% / / %
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Employer:
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Occupation:
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Address of Employer:
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Is Employer a member of the NASD?.................................../ /Yes / /No
SUITABILITY INFORMATION
1. Investment Objectives (check all that apply):
/ / Growth of Assets / / Conservation of Principal
/ / Other (specify)
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/ / Retirement Income / / Tax Sheltered Accumulations
2. I am comfortable assuming (check all that apply):
/ / Low Risk / / Moderate Risk / / High Risk
/ / Other (specify)
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3. Source of Funds:
/ / Current Income / / Qualified Plan Distribution
/ / IRA Rollover
/ / Personal Savings / / Mutual Fund Redemption
/ / Other (specify)
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/ / CD/Money Market Fund / / Insurance Proceeds
4. Did you receive the current prospectus for the life insurance or annuity
contract applied for?........................................../ /Yes / /No
5 Do you understand that the contract values including any death benefit may
increase or decrease, depending on the investment performance of the
Variable Sub-Account(s)?......................................./ /Yes / /No
6. If applying for a life insurance contract only, do you understand that the
contract may lapse if the Surrender Value becomes insufficient to cover the
Monthly Deductions?............................................/ /Yes / /No
7. Do you understand that any personalized illustrations received are based on
hypothetical rate of return assumptions which may not be indicative of
actual future investment experience of the Variable Sub-Account(s) or
actual interest credited to the Fixed Account?................./ /Yes / /No
8. Do you understand that all net premiums received before the Allocation
Date, which generally is within 10 days after the 30 day Right-to-Examine
Period, will initially be held in the Money Market Sub-Account until the
Allocation Date and then will be transferred in accordance with your
instructions specified below?................................../ /Yes / /No
9. Do you believe that this contract is consistent with your insurance needs
and financial objectives?....................................../ /Yes / /No
INITIAL PREMIUM ALLOCATION (TOTAL MUST EQUAL 100%, MINIMUM ALLOCATION NO LESS
THAN 5%, WHOLE PERCENTAGES ONLY)
[ % Fixed Account]
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[ % Lincoln National Bond Fund Sub-Account]
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[ % Delaware Trend Series Sub-Account]
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[ % Lincoln National Money Market Fund Sub-Account]
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[ % Delaware Growth and Income Series Sub-Account]
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[ % Delaware Select Growth Series Sub-Account]
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[ % Delaware International Equity Series Sub-Account]
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VL-3915AA(01/00) 1
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SPECIAL REQUESTS
1. To activate the TELEPHONE TRANSFER AND WITHDRAWAL PRIVILEGES OPTIONS in the
policy, please provide us with a 6 digit Personal Identification Number
(PIN#). If you do NOT wish to activate, please leave blank.
|___|___|___|___|___|___|.
2. Do you elect the DOLLAR COST AVERAGING ALLOCATION
OPTION?......................................................../ /Yes / /No
If yes, please select the frequency:
/ / Monthly / / Quarterly / / Semi-Annually / / Annually
Given the frequency indicated above, please provide the specific day of the
month when you wish this option to occur:
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Please indicate the $ or % to be transferred from the:
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/ / Money Market Sub-Account / / Fixed Account to the Sub-Accounts
selected below:
[$ or % Delaware Trend Series Sub-Account]
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[$ or % Delaware Growth and Income Series Sub-Account]
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[$ or % Delaware Select Growth Series Sub-Account]
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[$ or % Delaware International Equity Series Sub-Account]
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[$ or % Lincoln National Bond Fund Sub-Account]
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3. Do you elect the AUTOMATIC REBALANCING ALLOCATION
OPTION?......................................................../ /Yes / /No
(THIS OPTION IS NOT AVAILABLE IF THE DOLLAR COST AVERAGING OPTION IS
ELECTED)
If yes, please select the frequency:
/ / Quarterly / / Semi-Annually / / Annually
Given the frequency indicated above, please provide the specific day of the
month when you wish this option to occur:
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SIGNATURES
I understand that the amount and duration of the Death Benefit and other values
provided by this life insurance or annuity contract are based on the investment
experience of the Variable Account, the Fixed Account earnings and contract
charges. Variable Account Values may increase or decrease. These Variable
Account Values are NOT GUARANTEED as to fixed dollar amount.
To the best of my knowledge, the above answers are true and correctly recorded.
I believe the life insurance or annuity contract applied for is suitable for my
investment objectives and understand and agree that this Supplemental
Application shall be attached to and made a part of any issued contract.
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Signature of Applicant/Owner Date
The Applicant/Owner listed above has been informed of the risks involved in this
life insurance or annuity contract, and I certify that I have reasonable grounds
for believing that this contract is suitable for the Applicant/Owner's
objectives.
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Signature of Registered Representative Date
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VL-3915AA(01/00) 2
