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SEI Variable Annuity Application The Lincoln National Life
Investments Insurance Comapny
VARIABLE ANNUITY Fort Wayne, Indiana
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Instructions: Please type or print. ANY ALTERATIONS TO THIS APPLICATION MUST BE
INITIALED BY THE CONTRACT OWNER.
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1a Contract Owner
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_____________________________________________________
Full legal name or trust name*
_____________________________________________________
Contract owner e-mail address (if applicable)
_____________________________________________________
Street Address
_____________________________________________________
City State ZIP
_____________________________________________________
Trustee name*
Social Security number/TIN [_][_][_]-[_][_]-[_][_][_][_]
Date of birth [_][_] [_][_] [_][_] [_] Male [_] Female
Month Day Year
Home telephone number [_][_][_] [_][_][_]-[_][_][_][_]
Date of trust* [_][_] [_][_] [_][_] Is trust revocable?*
Month Day Year [_] Yes [_] No
Note: Maximum age of Contract Owner is 90.
*This information is required for trusts.
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1b Joint Contract Owner
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_____________________________________________________
Full legal name
Social Security number [_][_][_]-[_][_]-[_][_][_][_]
Date of birth [_][_] [_][_] [_][_] [_] Male [_] Female
Month Day Year [_] Spouse [_] Non-Spouse
Note: Maximum age of Joint Contract Owner is 90.
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2a Annuitant (if no Annuitant is specified the Contract Owner or Joint Owner if
younger will be the Annuitant)
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_____________________________________________________
Full legal name
_____________________________________________________
Street address
_____________________________________________________
City State ZIP
Social Security number [_][_][_]-[_][_]-[_][_][_][_]
Date of birth [_][_] [_][_] [_][_] [_] Male [_] Female
Month Day Year
Home telephone number [_][_][_] [_][_][_]-[_][_][_][_]
Note: Maximum age of Annuitant is 90.
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2b Contingent Annuitant
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_____________________________________________________
Full legal name
Social Security number [_][_][_]-[_][_]-[_][_][_][_]
Note: Maximum age of Contingent Annuitant is 90.
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3 Beneficiary(ies) Of Contract Owner (List additional beneficiaries on separate
sheet. If listing children use full legal names)
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_____________________________________________________
Primary: Full legal name or trust name*
%
_________________________________ ________________ ________
Relationship to Contract Owner SSN/TIN
_____________________________________________________
Primary: Full legal name
%
_________________________________ ________________ ________
Relationship to Contract Owner SSN/TIN
_____________________________________________________
Contingent: Full legal name or trust name
%
_________________________________ ________________ ________
Relationship to Contract Owner SSN/TIN
_____________________________________________________
Executor/Trustee name*
Date of trust* [_][_] [_][_] [_][_] Is trust revocable?*
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 (29953SEI).
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4 Type of SEI Variable Annuity Contract
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Nonqualified: [_] Initial Contribution OR [_] 1035 Exchange
Tax-Qualified (must complete plan type):
[_] Initial Contribution, Tax Year_______ OR [_] Transfer OR [_] Rollover
Plan Type (check one): [_] Roth IRA [_] Traditional IRA
Form 30269 1/00 Page 1 [Copyright information (SEI will provide]
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5 Allocation (This section must be completed.)
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Initial minimums: Nonqualified/403(b) $25,000 Qualified $25,000
If no allocations are specified, the entire amount will be allocated to the
Money Market Fund pending instructions from the Contract Owner.
Please allocate my contribution of: $ __________________________
Initial contribution
OR $ ________________________________________
Approximate amount from previous carrier
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SELECT ONE OF THE FOLLOWING PORTFOLIOS
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[_] Institutional Moderate Growth & Income
[_] Global Moderate Growth & Income
[_] Moderate Growth & Income
[_] Institutional Growth & Income
[_] Global Growth & Income
[_] Growth & Income
[_] Institutional Capital Growth
[_] Global Capital Growth
[_] Capital Growth
[_] Institutional Equity
[_] Global Equity
[_] Equity
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All contributions will be allocated to the funds in the percentages determined
by the portfolio manager.
Portfolio Rebalancing occurs each quarter according to the portfolios then
current percentages.
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OR
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SELECT YOUR OWN ALLOCATION
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Use whole percentages
% Large Cap Growth
_________
% Large Cap Value
_________
% Small Cap Growth
_________
% Small Cap Value
_________
% International Equity
_________
% Emerging Markets
_________
% Emerging Markets Debt
_________
% Core Fixed Income
_________
% High Yield
_________
% International Fixed
_________
% Money Market
_________
% Total (must = 100%)
_________
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Future contributions will follow the allocation above, unless DCA is selected.
To elect DCA, complete form 28065SEI.
To elect Portfolio Rebalancing or Cross-Reinvestment, complete the appropriate
form (available from your financial advisor).
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6 Automatic Withdrawals
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[_] Please provide me with automatic withdrawals totaling _____% of the total
contract value or $_________________ payable as follows:
(minimum of $50)
[_] Monthly [_] Quarterly [_] Semiannually [_] Annually
Begin withdrawals in [_][_] [_][_]
Month Year
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ELECT ONE: [_] Do withhold taxes [_] Do not withhold taxes
ELECT ONE: [_] Send check to address of record OR
[_] Send check to the following alternate address:
_______________________________________
_______________________________________
_______________________________________
Note: If no tax withholding selection is made, taxes will be withheld.
For direct deposit into your bank account, an electronic fund transfer form must
be completed and submitted with a voided check.
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7 Death Benefit Option
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If a death benefit is not selected, the default will be: Maximum of (account
value, return of premium).
ELECT ONE: [_] Account Value [_] Return of Premium [_] Annual Step Up
[_] 5% Step Up
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8 Automatic Bank Draft
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________________________________________________________________________________
Print account holder name(s) EXACTLY as shown on bank records
____________________________________________________________ ATTACH VOIDED CHECK
Bank name ABA number
________________________________________________________________________________
Bank street address City State ZIP
Automatic bank draft start date: [_][_] [_][_] [_][_]
Month Day (1-26) Year
____________________________ $_____________________________
Checking account number Monthly amount ($100 minimum)
I/We hereby request and authorize you to pay and charge to my/our account checks
or electronic fund transfer debits processed by and payable to the order of
Lincoln Life, P.O. Box [0000], Fort Wayne, IN 46801-[0000], provided there are
sufficient collected funds in said account to pay the same upon presentation. It
will not be necessary for any officer or employee of Lincoln Life to sign such
checks. I/We agree that your rights in respect to each such check shall be the
same as if it were a check drawn on you and signed personally by me/us. This
authority is to remain in effect until revoked by me/us, and until you actually
receive such notice I/we agree that you shall be fully protected in honoring any
such check or electronic fund transfer debit. I/We further agree that if any
such check or electronic fund transfer debit be dishonored, whether with or
without cause and whether intentionally or inadvertently, you shall be under no
liability whatsoever even though such dishonor results in the forfeiture of
insurance or investment loss to me/us.
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9 Telephone/Internet Authorization (Check box if this option is desired)
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[_] I/We hereby authorize and direct Lincoln Life to accept instructions via
telephone or 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 their affiliates and any mutual fund managed by
such affiliates and their directors, trustees, officers, employees and agents
for any losses arising from such instructions.
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10 Replacement Will the proposed contract replace any existing annuity XXXXXXX
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ELECT ONE: [_] No [_] Yes If yes, complete the 1035 Exchange or Qualified
Retirement Account Transfer form.
(Attach a replacement form if required by the state in which the application is
signed.)
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Company name
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Plan name Year issued
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Fraud Warning Residents of all 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.
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11 Signatures
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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 [XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX]
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. 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.
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Signed at (city) State
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Signature of Contract Owner Joint Contract Owner (if applicable)
Date [_][_] [_][_] [_][_]
Month Day Year
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Signed at (city) State
Date [_][_] [_][_] [_][_]
Month Day Year
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Signature of Annuitant (Annuitant must sign if Contract Owner is a trust or
custodian.)
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FINANCIAL ADVISER MUST COMPLETE REVERSE SIDE (PAGE 4)
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THE FOLLOWING SECTIONS MUST BE COMPLETED BY THE FINANCIAL ADVISER OR SECURITIES
DEALER. Please type or print.
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12 Insurance In Force. Will the proposed contract replace any existing annuity
or life insurance contract?
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ELECT ONE: [_] No [_] Yes If yes, please list the insurance in force on the
life of the proposed Contract Owner(s) and
Annuitant(s):
$
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Company name Year issued Amount
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13 Additional Remarks
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14 Dealer Information
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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 12.
[_] No Load
[_] C-Share
_______________________________________________ [_][_][_] [_][_][_]-[_][_][_][_]
Registered representative's name (print as it Registered representative's
appears on NASD licensing) telephone number
_______________________________________________ [_][_][_]-[_][_]-[_][_][_][_]
Client account number at dealer (if applicable) Registered representative's SSN
________________________________________________________________________________
Dealer's name
________________________________________________________________________________
Branch address City State ZIP
[_] CHECK IF BROKER CHANGE OF ADDRESS
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15 Representative's Signature
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The representative hereby certifies that he/she witnessed the signature(s) in
section 10 and that all information contained in this application is true to the
best of his/her knowledge and belief.
________________________________________________________________________________
Signature
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Send completed application -- with a check made payable to Lincoln Life -- to
your investment dealer's home office or to:
SEI
Investments
VARIABLE ANNUITY
Lincoln Life
P.O. Box [0000]
Fort Wayne, IN 46801-[0000]
By Express Mail: Lincoln Life
Attention: SEI Operations
1300 South Clinton Street
Fort Wayne, IN 46802
If you have any questions regarding this application, call Lincoln Life at
[800 000-0000.]
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