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The Lincoln National Life
[LOGO HERE] Wells Fargo Insurance Company
Variable Annuity Application 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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_______________________________________ Social Security number/TIN [_][_][_]-[_][_]-[_][_][_][_]
Full legal name or trust name*
Date of birth [_][_] [_][_] [_][_] [_] Male [_] Female
Month Day Year
_______________________________________
Street address
Home telephone number [_][_][_] [_][_][_]-[_][_][_][_]
_______________________________________
City State ZIP
Date of trust* [_][_] [_][_] [_][_] Is trust revocable?*
Month Day Year [_] Yes [_] No
_______________________________________
Trustee name*
Note: Maximum age of Contract Owner is 85. *This information is required for trusts.
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1b Joint Contract Owner
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Social Security number [_][_][_]-[_][_]-[_][_][_][_]
_______________________________________
Full legal name [_] Male [_] Female
Note: Maximum age of Joint Contract Owner is 85. Date of birth [_][_] [_][_] [_][_]
Month Day Year [_] Spouse [_] Non-spouse
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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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Social Security number [_][_][_]-[_][_]-[_][_][_][_]
_______________________________________
Full legal name Date of birth [_][_] [_][_] [_][_] [_] Male [_] Female
Month Day Year
_______________________________________
Street address Home telephone number [_][_][_] [_][_][_]-[_][_][_][_]
_______________________________________
City State ZIP
Note: Maximum age of Annuitant is 85.
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2b Contingent Annuitant
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Social Security number [_][_][_]-[_][_]-[_][_][_][_]
_______________________________________
Full legal name
Note: Maximum age of Annuitant is 85.
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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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__________________________________________________ ____________________________________ ________________ _________%
Full legal name [_] Primary [_] Contingent Relationship to Contract Owner SSN/TIN
or trust name*
__________________________________________________ ____________________________________ ________________ _________%
Full legal name [_] Primary [_] Contingent Relationship to Contract Owner SSN/TIN
or trust name*
__________________________________________________ ____________________________________ ________________ _________%
Full legal name [_] Primary [_] Contingent Relationship to Contract Owner SSN/TIN
or trust name*
__________________________________________________ Date of trust* [_][_] [_][_] [_][_] Is trust revocable?*
Executor/Trustee name* 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 (29953WF).
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4 Type of Wells Fargo Variable Annuity Contract
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Nonqualified: [_] Initial Contribution OR [_] 1035 Exchange
Tax-Qualified (must complete plan type): [_] Transfer OR [_] Rollover
Plan Type (check one): [_] Roth IRA [_] Traditional IRA
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Form 30467WF 11/00 Page 1 [ ]
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5a Allocation (This section must be completed.)
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Initial minimum: $25,000
Future contributions will follow the allocation below. If
DCA option is selected, the entire amount of each future
contribution will follow the allocation in Section 5b.
If no allocations are specified in Section 5a or 5b, the entire
amount will be allocated to the Money Market Fund pending
instructions from the contract owner.
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Total initial contribution amount $ _______________
Total DCA amount $ _______________
(enter amount in Section 5b)
Remaining amount to be allocated $ _______________
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INTO THE FUND(S) BELOW
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Use whole percentages
______________% Advisers Management Trust Balanced
______________% Advisers Management Trust Mid Cap Growth
______________% Advisers Management Trust Regency
______________% AFIS Global Small Capitalization Fund
______________% AFIS Growth Fund
______________% AFIS International Fund
______________% Aspen Aggressive Growth
______________% Aspen Worldwide
______________% Delaware Group Premium Emerging Markets Series
______________% Delaware Group Premium Growth & Income Series
______________% Delaware Group Premium High Yield Series
______________% Delaware Group Premium Reit Series
______________% Delaware Group Premium Small Cap Value Series
______________% Delaware Group Premium Trend Series
______________% Delaware Group Premium U.S. Growth
______________% Evergreen VA Omega
______________% Evergreen VA Special Equity
______________% Evergreen VA Strategic Income
______________% Goldman Sachs Core Small Cap Equity
______________% Goldman Sachs Mid Cap Value
______________% Lincoln National Capital Appreciation
______________% Lincoln National Growth & Income
______________% VIP Contrafund
______________% VIP Growth Opportunities
______________% VIP Overseas
______________% VIP Capital Opportunities
______________% VIP Emerging Growth
______________% Vip Utilities
______________% Wells Fargo Variable Trust Asset Allocation
______________% Wells Fargo Variable Trust Corporate Bond
______________% Wells Fargo Variable Trust Equity-Income
______________% Wells Fargo Variable Trust Equity-Index
______________% Wells Fargo Variable Trust Equity Value
______________% Wells Fargo Variable Trust Growth
______________% Wells Fargo Variable Trust International Growth
______________% Wells Fargo Variable Trust Large Company Growth
______________% Wells Fargo Variable Trust Money Market
______________% Wells Fargo Variable Trust Small Company Growth
______________% Wells Fargo Variable Trust Specialized Technology
Fixed Account: ___________ % 4 years
___________ % 5 years
__________ % 1 year ___________ % 6 years
___________ % 7 years
___________ % 8 years
___________% 2 years ___________ % 9 years
___________% 3 years ___________ % 10 years
% Total (must = 100%)
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5b Dollar Cost Averaging (Complete only if electing DCA.)
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$2,000 minimum required.
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Total amount to DCA: $ _____________________
OR
MONTHLY amount to DCA: $ _____________________
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OVER THE FOLLOWING PERIOD: _____________________
MONTHS (6-60)
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FROM THE FOLLOWING HOLDING ACCOUNT (check one):
[_] 1 Year Fixed Account (Only available for 12 months or less.)
*The DCA holding account
[_] Wells Fargo Money Market Fund and the DCA fund elected
cannot be the same.
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INTO THE FUND(S) BELOW
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Use whole percentages
______________% Advisers Management Trust Balanced
______________% Advisers Management Trust Mid Cap Growth
______________% Advisers Management Trust Regency
______________% AFIS Global Small Capitalization Fund
______________% AFIS Growth Fund
______________% AFIS International Fund
______________% Aspen Aggressive Growth
______________% Aspen Worldwide
______________% Delaware Group Premium Emerging Markets Series
______________% Delaware Group Premium Growth & Income Series
______________% Delaware Group Premium High Yield Series
______________% Delaware Group Premium Reit Series
______________% Delaware Group Premium Small Cap Value Series
______________% Delaware Group Premium Trend Series
______________% Delaware Group Premium U.S. Growth
______________% Evergreen VA Omega
______________% Evergreen VA Special Equity
______________% Evergreen VA Strategic Income
______________% Goldman Sachs Core Small Cap Equity
______________% Goldman Sachs Mid Cap Value
______________% Lincoln National Capital Appreciation
______________% Lincoln National Growth & Income
______________% VIP Contrafund
______________% VIP Growth Opportunities
______________% VIP Overseas
______________% VIP Capital Opportunities
______________% VIP Emerging Growth
______________% Vip Utilities
______________% Wells Fargo Variable Trust Asset Allocation
______________% Wells Fargo Variable Trust Corporate Bond
______________% Wells Fargo Variable Trust Equity-Income
______________% Wells Fargo Variable Trust Equity-Index
______________% Wells Fargo Variable Trust Equity Value
______________% Wells Fargo Variable Trust Growth
______________% Wells Fargo Variable Trust International Growth
______________% Wells Fargo Variable Trust Large Company Growth
______________% Wells Fargo Variable Trust Money Market
______________% Wells Fargo Variable Trust Small Company Growth
______________% Wells Fargo Variable Trust Specialized Technology
______________% TOTAL (must = 100%)
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Future contributions will not automatically start a new DCA
program. Instructions must accompany each DCA contribution.
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5c Cross-Reinvestment or Portfolio Rebalancing
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To elect either of these options, please complete the Cross-Reinvestment
form (28051WF) or the Portfolio Rebalancing form (28887WF).
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6 Death Benefit Option
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[_] I/We hereby elect the xxxxx death benefit option. I/We understand that
if this benefit is not elected, my/our death benefit will be the Enhanced
Guaranteed Minimum Death Benefit.
* The xxxxx may only be elected if the Contract Owner, Joint Owner (if
applicable), and Annuitant are all under age 80.
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7 Automatic Withdrawals
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Note: Withdrawals exceeding 10% of the total contract value per year may be
subject to contingent deferred sales charges. Withdrawals are also
subject to market value adjustments (for additional information, see
Section II). Withdrawal minimum: $50 per distribution/$300 annually.
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[_] Please provide me with automatic withdrawals [_] Please provide me with automatic withdrawals
totaling ______% (may be between 1-15%) of premium of $________________________
payments payable as follows:
[_] Monthly [_] Quarterly [_] Semiannually [_] Annually
[_] Monthly [_] Quarterly [_] Semiannually [_] Annually
Begin withdrawals in [_][_] [_][_]
Begin withdrawals in [_][_] [_][_] Month Year
Month Year -----------------------------------------------------------
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Note: If no tax withholding selection is made, federal taxes will be
withheld at a rate of 10%.
ELECT ONE: [_] Do withhold taxes
Amount to be withheld $___________________ OR _________%
[_] Do not withhold taxes
ELECT ONE: [_] Send check to address of record
OR [_] Send check to the following alternate address:
[_] Direct deposit
______________________________
For direct deposit into your
bank account, the Electronic ______________________________
Fund Transfer Authorization
form (27326WF) must be ______________________________
completed and submitted with
a voided check or a savings
deposit slip.
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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 Year
(1-28)
_____________________________________________________ $___________________
Checking account number Monthly amount
I/We hereby request and authorize you to pay and charge to my/our accounts,
checks or electronic fund transfer debits processed by and payable to the
order of Lincoln Life, P.O. Box 7882, Fort Wayne, IN 46801-7882, 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 the 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 or
life insurance contract?
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ELECT ONE: [_] No [_] Yes If yes, complete the 1035 Exchange or
Qualified Retirement Account Transfer form.
(Attach a state replacement form if required by the state in which the
application is signed.)
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_________________________________________________________________________________________________
Company name
_________________________________________________________________________________________________
Plan name Year issued
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Fraud Warning Residents of all states except Virginia 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 Wells Fargo Variable
Annuity 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. I/We
understand that all payments and values based on the fixed account are
subject to a market value adjustment formula that may increase or decrease
the value of any transfer, partial surrender, or full surrender from the
fixed account made prior to the end of a guaranteed period. 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 Date [_][_] [_][_] [_][_]
Month Day Year
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Signature of Contract Owner Joint Contract Owner (if applicable)
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Signed at (city) State Date [_][_] [_][_] [_][_]
Month Day Year
______________________________________________________________________________________
Signature of Annuitant (Annuitant must sign if Contract Owner is a trust or custodian.)
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Investments Products:
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. Are NOT insured by the FDIC
. Are NOT obligations or deposits of any Wells Fargo Bank nor guaranteed by
the Bank
. Involve investment risk, including possible loss of principal
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FINANCIAL ADVISER MUST COMPLETE REVERSE SIDE (PAGE 5)
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THE FOLLOWING SECTIONS MUST BE COMPLETED BY THE SECURITIES DEALER OR
FINANCIAL ADVISER. 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):
(Attach a state replacement form if required by the state in which the
application was signed.)
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_____________________________________________________________________________________________ $_____________
Company name Year issued Amount
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13 Additional Remarks
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_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
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14 Dealer Information
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Option: [_] 1 [_] 2
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 13.
___________________________________________________________________________ [_][_][_]-[_][_][_]-[_][_][_][_]
Registered representative's name (print as it appears on NASD licensing) Registered representative's telephone number
___________________________________________________________________________ [_][_][_]-[_][_]-[_][_][_][_]
Client account number at dealer (if applicable) Registered representative's SSN
________________________________________________________________________________________________________________________________
Dealer's name
________________________________________________________________________________________________________________________________
Branch address City State ZIP
________________________________________________________________________________________________________________________________
Branch number Representative number
[_] 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 11 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:
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[LOGO APPEARS HERE] Express Mail:
---------------------- Lincoln Life Lincoln Life
P.O. Box 7882 Attention: Wells Fargo Operations
Fort Wayne, IN 46801-7882 1300 South Clinton Street
Fort Wayne, IN 46802
If you have any questions regarding this application, please call Lincoln Life at 800-458-0822.
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