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Exhibit 5
[WADDELL & REED FINANCIAL SERVICES LOGO]
WADDELL & REED ADVISORS
SELECT PLUS ANNUITY(SM)
ENROLLMENT CARD
GROUP DEFERRED VARIABLE ANNUITY
[$25,000] MINIMUM PURCHASE PAYMENT
NATIONWIDE LIFE INSURANCE COMPANY
P.O. BOX 182449
COLUMBUS, OH 43218-2449
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PLAN TYPE AN OPTION MUST BE SELECTED This Certificate Agreement is established as a:
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[ ] NON-QUALIFIED [ ] 401(a) (Investment Only) DISCLOSURE FORM REQUIRED
[ ] IRA [ ] 403(b) TSA (Non-ERISA only) DISCLOSURE FORM REQUIRED
[ ] Roth IRA [ ] ORP 403(b) DISCLOSURE FORM REQUIRED
[ ] SEP IRA FORM 5305 REQUIRED [ ] CRT (Charitable Remainder Trust) DISCLOSURE FORM REQUIRED
[ ] SIMPLE IRA ADDITIONAL FORMS REQUIRED
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CERTIFICATE OWNER [ ] CONTINGENT CERTIFICATE OWNER
[ ] JOINT CERTIFICATE OWNER *
*SPOUSE ONLY EXCEPT IN HI, NJ AND VT
Last Name or Trust Name Last Name
First Name or Trust Name (continued) MI First Name MI
Address Address
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Sex [ ] M [ ] F Birthdate / / Sex [ ] M [ ] F Birthdate / /
-------------------- -------------------------
MM DD YYYY MM DD YYYY
Soc. Sec. No. or Tax ID Soc. Sec. No. or Tax ID
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ANNUITANT COMPLETE ONLY IF DIFFERENT FROM CERTIFICATE OWNER [ ] CONTINGENT ANNUITANT
Last Name Last Name
First Name MI First Name MI
Address Address
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Maximum issue age through age 90 Maximum issue age through age 90
Sex [ ] M [ ] F Birthdate / / Sex [ ] M [ ] F Birthdate / /
---------------------- ---------------------
MM DD YYYY MM DD YYYY
Soc. Sec. No. or Tax ID Soc. Sec. No. or Tax ID
-------------------------------- ------------------------------------------
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BENEFICIARY WHOLE PERCENTAGES ONLY, ALL PRIMARY BENEFICIARIES MUST TOTAL 100%; ALL CONTINGENT BENEFICIARIES MUST TOTAL 100%.
Relationship
Primary Contingent Print Full Name (Last, First, MI) Allocation to Annuitant Soc. Sec. No.
[ ] %
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[ ] [ ] %
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[ ] [ ] %
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FHL-679 PRODUCT OF NATIONWIDE LIFE AND ANNUITY LIFE INSURANCE CO. AO (8/2000)
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*SELECTION OF ANY OF THE FOLLOWING RIDERS WILL RESULT IN AN INCREASE IN YOUR
VARIABLE ACCOUNT CHARGE. PLEASE SEE THE PROSPECTUS.
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DEATH BENEFIT OPTIONS: OTHER OPTIONS:
ONLY ONE DEATH BENEFIT MAY BE SELECTED. IF NO OPTION IS SELECTED,
THE DEATH BENEFIT WILL BE THE STANDARD DEATH BENEFIT AS DESCRIBED INCOME GUARD GUARANTEED ANNUITIZATION VALUE RIDER AVAILABLE TO
IN THE CERTIFICATE AGREEMENT. ANNUITANTS WHO ARE 82 OR LESS. THIS OPTION IS NOT AVAILABLE IN
CA, MD, NJ OR ND.
[ ] Standard Death Benefit
FOLLOWING OPTION IS AVAILABLE FOR ANNUITANTS AGE 84 OR LESS [ ] 5% Interest GAV *
[ ] Maximum Anniversary Death Benefit* [ ] Maximum Certificate Anniversary GAV *
FOLLOWING OPTION IS AVAILABLE FOR ANNUITANTS AGE 80 OR LESS OTHER RIDER OPTIONS:
[ ] Five Year Reset Death Benefit * [ ] Extra Credit *
[ ] Nursing Home and Long Term Care Rider *
(NURSING HOME AND LONG TERM CARE RIDER NOT AVAILABLE IN MA
AND NJ)
[ ] Nursing Home and Extended Care Rider in WA only *
[ ] Reduced Purchase Payment Rider *
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PURCHASE PAYMENT [ ] ROLLOVER [ ] PAYMENT ENCLOSED [ ] TRANSFER/1035 (requires transfer form)
Purchase Payment $_________ submitted (minimum [$25,000]). A copy of this enrollment card properly signed by the registered
representative will constitute receipt for such amount. If this enrollment card is declined by the Company, there will be
no liability on the part of the Company, and any payments submitted with this enrollment card will be refunded.
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PURCHASE PAYMENT ALLOCATION WHOLE PERCENTAGES ONLY,
MUST TOTAL 100%
THE UNDERLYING INVESTMENT OPTIONS LISTED ON THIS ENROLLMENT CARD ARE ONLY AVAILABLE IN VARIABLE ANNUITY INSURANCE PRODUCTS ISSUED
BY LIFE INSURANCE COMPANIES OR, IN SOME CASES, THROUGH PARTICIPATION IN CERTAIN QUALIFIED PENSION OR RETIREMENT PLANS. THEY ARE
NOT OFFERED TO THE GENERAL PUBLIC DIRECTLY
W & R TARGET FUNDS, INC.
MVA/GUAR. TERM OPTION (GTO)
% Asset Strategy Portfolio
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% Balanced Portfolio % 3 Year
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% Bond Portfolio % 5 Year $1,000 minimum
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% Growth Portfolio % 7 Year option
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% High Income Portfolio % 10 Year
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% Core Equity Portfolio
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% International Portfolio NATIONWIDE LIFE INS. CO.
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% Limited-Term Bond Portfolio % Fixed Account (NOT AVAILABLE IN SC)
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% Money Market Portfolio
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% Science and Technology Portfolio
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% Small Cap Portfolio
------
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FHL-679
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REMARKS
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NOTICE TO MN, ND, SC, SD AND VT RESIDENTS:
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ANNUITY PAYMENTS, DEATH BENEFITS, SURRENDER VALUES, AND OTHER CERTIFICATE VALUES
PROVIDED BY THIS CERTIFICATE AGREEMENT, WHEN BASED ON THE INVESTMENT EXPERIENCE
OF A SEPARATE ACCOUNT, OR WHEN SUBJECT TO A MARKET VALUE ADJUSTMENT ARE
VARIABLE, MAY INCREASE OR DECREASE IN ACCORDANCE WITH THE FLUCTUATIONS IN THE
NET INVESTMENT FACTOR OR APPLICATION OF A MARKET VALUE ADJUSTMENT, AS
APPLICABLE, AND ARE NOT GUARANTEED AS TO FIXED-DOLLAR AMOUNT, UNLESS OTHERWISE
SPECIFIED. A MARKET VALUE ADJUSTMENT MAY BE ASSESSED ON ANY GUARANTEED TERM
OPTIONS THAT HAVE NOT MATURED JUST PRIOR TO ANNUITIZATION AND WOULD BE IN
ADDITION TO THE SCHEDULED SURRENDER PENALTY CHARGE.
ADDITIONALLY, ANY BENEFITS, VALUES OR PAYMENTS BASED ON PERFORMANCE OF THE
UNDERLYING INVESTMENT OPTIONS MAY VARY AND ARE NOT GUARANTEED BY NATIONWIDE LIFE
INSURANCE COMPANY, ANY OTHER INSURANCE COMPANY, BY THE U.S. GOVERNMENT, OR ANY
STATE GOVERNMENT. THEY ARE NOT FEDERALLY INSURED BY THE FDIC, THE FEDERAL
RESERVE BOARD OR ANY AGENCY FEDERAL OR STATE.
NOTICE TO AR, KY, LA, ME, NM AND OH RESIDENTS:
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ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY
INSURANCE COMPANY OR OTHER PERSON, FILES FOR INSURANCE OR STATEMENT OF CLAIM
CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A
FRAUDULENT INSURANCE ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO
CRIMINAL AND CIVIL PENALTIES, FINES, IMPRISONMENT, OR A DENIAL OF INSURANCE
BENEFITS.
FOR AZ RESIDENTS ONLY - TEN DAY FREE LOOK:
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TO BE SURE THAT THE CERTIFICATE OWNER IS SATISFIED WITH THIS CERTIFICATE
AGREEMENT, THE CERTIFICATE OWNER HAS TEN DAYS TO EXAMINE THE CERTIFICATE
AGREEMENT AND RETURN IT TO THE HOME OFFICE OR THE AGENT THROUGH WHOM IT WAS
PURCHASED FOR ANY REASON. WHEN THE CERTIFICATE AGREEMENT IS RECEIVED IN THE HOME
OFFICE, THE COMPANY WILL RETURN THE CERTIFICATE VALUE TO THE CERTIFICATE OWNER,
WITHOUT DEDUCTION FOR ANY SALES CHARGES OR ADMINISTRATIVE FEE AS OF THE DATE OF
CANCELLATION, WHERE PERMITTED BY LAW.
FOR AZ RESIDENTS ONLY:
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UPON WRITTEN REQUEST, THE COMPANY AGREES TO PROVIDE, WITHIN A REASONABLE TIME,
REASONABLE FACTUAL INFORMATION REGARDING THE BENEFITS AND PROVISIONS OF THE
ANNUITY CERTIFICATE TO THE CERTIFICATE OWNER.
FOR DC RESIDENTS ONLY
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WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER
FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE
IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS
IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE
APPLICANT.
FOR NJ RESIDENTS ONLY:
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ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN ENROLLMENT
CARD FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
FOR WA RESIDENTS ONLY:
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ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A
LOSS OR KNOWINGLY MAKES A FALSE STATEMENT ON AN ENROLLMENT CARD FOR INSURANCE
MAY BE GUILTY OF A CRIMINAL OFFENSE UNDER STATE LAW.
FHL-679
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CERTIFICATE OWNER SIGNATURES
THE CERTIFICATE PAYMENTS OR VALUES UNDER THE VARIABLE ANNUITY PROVISIONS OF THE
CERTIFICATE AGREEMENT ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR
AMOUNT.
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[ ] Yes [ ] No Do you have any reason to believe the Certificate Agreement
applied for is replacing existing annuities or insurance ?
[ ] Please send me a copy of the statement of additional
information to the prospectus.
[ ] I consent to having the Company send my prospectus(es),
confirmation statements, quarterly statements, annual
statements, and other product information to my e-mail address
shown below.
CERTIFICATE OWNER'S E-MAIL ADDRESS
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I hereby represent my answers to the above questions to be accurate and complete
and acknowledge that I have received a copy of the current prospectus for this
variable annuity Certificate Agreement .
STATE IN WHICH ENROLLMENT CARD WAS SIGNED DATE
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CERTIFICATE OWNER JOINT CERTIFICATE OWNER
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Signature Signature
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REGISTERED REPRESENTATIVE INFORMATION
[ ] Yes [ ] No Do you have any reason to believe the Certificate Agreement
applied for is to replace existing annuities or insurance?
REGISTERED REPRESENTATIVE SIGNATURE
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REGISTERED REPRESENTATIVE'S NAME (print)
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REGISTERED REPRESENTATIVE'S SSN#
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FIRM NAME PHONE ( )
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ADDRESS
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FHL-679
