contract change request and medical questionnaire · apo-1270-r 11/2013 contract change request and...

APO-1270-R 11/2013

Contract Change Request and Medical Questionnaire Mail to: Nationwide Life Insurance Company and Nationwide Life and Annuity Insurance Company Individual Annuities, P.O. Box 182021, Columbus, Ohio, 43218-2021, 1-800-848-6331, Fax to: 1-888-634-4472 of 5

Supplemental information MUST be completed for all of the following requests.

1. Owner Information (Please print.) All fields in this section are required.

2. Change of Annuitant (Annuitant changes are not permitted on existing contracts with the L.inc Option.) Must include completed New Business Application and completed Medical Questionnaire.

2a. Proposed Primary AnnuitantAnnuitant First/Last Name:

Relationship to current Contract Owner:

Date of Birth: State of Birth: Soc. Sec. No. – –

Address:

City/State/ZIP:

Telephone Number: ( ) E-mail Address:

The Annuity Commencement Date* will automatically be updated to the later of the new annuitant’s 95th birthday or two (2) years from the date this form is received in good order, unless another future date is indicated below:

Annuity Commencement Date: / / (Optional)

MM DD YYYY*Annuity Commencement Date (ACD) is the date on which annuity payments are scheduled to begin. The owner can change this date at any time. We will send you notices regarding the ACD when action is required.

2b. Proposed Contingent Annuitant/Co-Annuitant (If permitted.) Check one box only: Contingent Annuitant Co-AnnuitantAnnuitant First/Last Name:


Date of Birth: State of Birth: Soc. Sec. No. – –

Address:

City/State/ZIP:


Owner First/Last Name:

Contract Number:

E-mail Address:( )Telephone Number:

Social Security Number:

Joint Owner First/Last Name: (If applicable)

Social Security Number:

Date of Birth:

Owner’s Address:

City/State/ZIP:

APO-1270-R 11/2013

Contract Change Request and Medical Questionnaire of 5

3. New Contract Owner• Ownership changes may result in a taxable event. Please contact your tax or legal advisor before proceeding• Ownership changes are not permitted on existing contracts with The Nationwide Lifetime Income Rider® (L.inc)• Where permitted under law, if the contract owner is changed or the contract is assigned on a Nationwide DestinationSM

B (2.0), Nationwide DestinationSM L (2.0), Nationwide DestinationSM EV (2.0), Nationwide DestinationSM Navigator (2.0), Nationwide DestinationSM All American Gold (2.0), Waddell & Reed Advisors Select Preferred AnnuitySM (2.0) contract, the Standard Death Benefit or any enhanced death benefit will terminate and the death benefit will be the Contract Value, and, if elected, the Nationwide Lifetime Income Rider®( L.inc) on your contract will terminate, except for the following circumstances: 1) the new contract owner or Assignee assumes full ownership of the contract and is essentially the same person (e.g. an individual ownership changed to the personal revocable trust, a change to the contract owner’s spouse during the contract owner’s lifetime, a change to a court-appointed guardian representing the contract owner during the contract owner’s lifetime, etc); 2) ownership of an IRA or Roth IRA is being changed from one custodian to another, from the contract owner to a custodian, or from a custodian to the contract owner; or 3) the assignment is for the purpose of effectuating a 1035 exchange of the contract (i.e. the benefits may continue during the temporary assignment period and not terminate until the contract is actually surrendered)

3a. New Primary OwnerOwner First/Last Name:


Date of Birth: Soc. Sec. No. or Tax ID: – –

Address:

City/State/ZIP:


You must provide new beneficiary(ies), current beneficiary(ies) will not carry over. If no beneficiary(ies) is named, Nationwide will default to the new Primary Owner’s Estate

3b. New Joint/Contingent Owner (If applicable.) Check one box only: Joint Owner Contingent OwnerOwner First/Last Name:


Date of Birth: Soc. Sec. No. or Tax ID: – –

Address:

City/State/ZIP:


4. DisclosurePursuant to its reliance on SEC Rule 12h-7, Nationwide Life Insurance Company (“Company”) is required to take steps reasonably designed to ensure that a trading market for certain variable annuities does not develop. To prevent the devel-opment of a trading market, the Company reserves the right to not approve a change of ownership or assignment, where permitted by law.

5. Important InformationI understand the purpose and intent of the contract referenced above is to offer benefits to individuals and their beneficiaries. I hereby acknowledge that I do not represent a corporate entity or institutional investor. I do not intend to assign any benefits under this contract to a corporate entity or institutional investor. Where permitted by law, Nationwide may reject assignments and/or contract owner changes that may alter the nature of the risk Nationwide intended to accept when the contract was issued.

APO-1270-R 11/2013

6. Change Beneficiary Designation Allocation to all Primary Beneficiaries must equal 100%. Fractional percentages (i.e. 1/3 or 33.3%) will not be honored.

6a. New Primary Beneficiaries Pay all Primary Beneficiaries equally

Legal First Name: MI: Last Name:

Relationship to Annuitant: Allocation (whole % only): %

Social Security Number: – – Sex: M F Date of Birth:

Address:

City/State/ZIP:





Address:

City/State/ZIP:


6b. Contingent Beneficiaries Pay all Contingent Beneficiaries equally




Address:

City/State/ZIP:





Address:

City/State/ZIP:



APO-1270-R 11/2013

7. Change Investment Professional Please provide the following information for the agent(s) to be placed on the policy:

Agent Name Social Security Broker Dealer Name Split % Number (Required) (Whole numbers only)

1. Primary Agent Name** (First, Middle, Last)

2.

3.

4. A maximum of 4 Agents and 2 Broker firms are permitted.**The primary agent will receive the agent copy of all contract confirmations and statements and will have Power of Attorney, if applicable.

8. Signatures Required for Any changes in the previous sections.

Owner’s Name: Date:

Owner’s Signature: X

Joint Owner’s Name: Date:

Joint Owner’s Signature: X

New Owner’s Name: Date:

New Owner’s Signature: X

New Joint Owner’s Name: Date:

New Joint Owner’s Signature: X

9. Application Supplement Use this form to provide information for a new business application or if you have requested an annuitant change on the preceding pages.

Annuitant Medical Questionnaire Annuitant Co-Annuitant YES NO YES NO

1. Have you ever had an application for insurance declined, postponed, rated up or limited? 2. Have you ever had indications of, been treated or counseled for alcoholism, drug addiction, nervous or mental disorder? 3. Have you ever had indications of, been treated for or taken medication for high blood pressure, epilepsy, or stroke? 4. Have you ever had indications of, been treated for or taken medications for chest pains, heart attack or other heart disorder, diabetes, kidney disorder, lung disorder, blood disorder or any cancer or malignancy? 5. Have you ever received treatment for or been diagnosed as having acquired immune deficiency syndrome (AIDS), AIDS related complex (ARC), or received a positive result to a HIV Test? 6. Within the past five years, have you had any disease, disorder, injury, test or operation which has not been previously mentioned?

7. Annuitant Height and Weight: Co-Annuitant Height and Weight:

Please provide full details regarding any of the above questions that are answered “Yes” and include the full name and address of any provider of medical services.


APO-1270-R 11/2013

10. MIB, Inc. Disclosure NoticeInformation regarding your insurability will be treated as confidential. Nationwide Life Insurance Company and Nationwide Life and Annuity Insurance Company, or its reinsurer(s) may, however make a brief report thereon to MIB, Inc., a non profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB, Inc. member company for life or health insurance coverage or a claim for benefits is submitted to such a company, MIB, Inc. will arrange disclosure of any information it may have in your file. If you question the accuracy of information in MIB, Inc.’s file you may contact MIB, Inc. and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address of MIB, Inc. information office is 50 Braintree Hill, Suite 400, Braintree, Massachusetts 02184-8734, telephone number 1-866-692-6901. The e-mail address of MIB, Inc.’s information office is www.mib.com. Nationwide Life Insurance Company and Nationwide Life and Annuity Insurance Company or it reinsurer(s) may also release information in its file to other insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted.

11. Medical Information Authorization Required for Annuitant Change.

I authorize: any licensed physician or medical practitioner, any hospital, clinic, any pharmacy or pharmacy benefit managers, and other sources who maintain prescription drug records and related information, or other medical or medically related facility; any insurance company MIB, Inc.; or any other organization, institution, or person, to disclose any information concerning me, including, but not limited to, my entire medical/health record to the Medical Director of Nationwide Life Insurance Company and Nationwide Life and Annuity Insurance Company or its affiliates, including, but not limited to, RSA Medical, for the purpose of underwriting my application in order to determine my eligibility for Life Insurance and to investigate claims. By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this form; and I instruct any physician; health care professional; hospital; clinic; pharmacy or pharmacy benefit managers; medical facility; or other health care provider to release and disclose my entire medical/health records without restriction. I understand that any information that is disclosed pursuant to this form may be re-disclosed and no longer be covered by federal rules governing privacy and confidentiality of health information. This form, or a copy of it, will be valid for a period of not more than two and one-half years (30 months) from the date it was signed. I understand that I have the right to revoke this form in writing, at any time, by sending a written request for revocation to Nationwide Life Insurance Company and Nationwide Life and Annuity Insurance Company, Attention: ANBAS Support, P.O. Box 182021, Columbus, OH 43218. I understand that a revocation is not effective to the extent that any of my providers have relied on this form; or to the extent that Nationwide Life Insurance Company and Nationwide Life and Annuity Insurance Company has a legal right to contest a claim under an insurance policy or to contest the policy itself. I further understand that if I refuse to sign this form to release my complete records, or, if I revoke this authorization before a policy is issued, Nationwide Life Insurance Company and Nationwide Life and Annuity Insurance Company may not be able to process my application. I understand that my authorized representative or I have a right to a copy of this form by sending a request to Nationwide in writing.

Proposed Annuitant Name: Date:

Proposed Annuitant Signature: X

Proposed Co-Annuitant Name: Date:

Proposed Co-Annuitant Signature: X

If you are providing supplementary information for a new business application, please specify on the application to see supplement and attach this form to the new business application.


contract change request and medical questionnaire · apo-1270-r 11/2013 contract change request and...

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