NATIONWIDE INSURANCE COMPANIES



|NATIONWIDE INSURANCE COMPANIES |DATE ATTAINED CAREER STATUS|

|INDEPENDENT CONTRACTOR AGENT INSURANCE ENROLLMENT FORM | |

|COMPLETE IN FULL (not valid without signature & date) | | | |

| |DATE OF BIRTH |

| | | | | | |

|LAST NAME FIRST NAME MI ST# AGENT # |MARITAL STATUS |

|AGENT MEDICAL – CCN PPO |MEDICARE COMPLEMENT |SINGLE |( |

|((CHECK ONE) |((CHECK ONE) |MARRIED |( |

| |REJECT all Medical | | | | |Medicare Self Spouse | |DIVORCED |( |

| |$2000 deductible 80/70 | | | | |$ 250 With drug | | | |

| | | | | | | | | |SEX |

| |$5000 deductible 100/70 | | | | | | | | |

| | | | | | | |CHILDREN |Y |N |

| | | | | | | | | |

| | |Apply |Reject | | | | | |

| |SPOUSE MEDICAL | | | | |

| |CHILD MEDICAL | | | | |

| |SPOUSE+CHILD MEDICAL | | | | |

| | |

| | |

| |AGENT LIFE COV. | | | |APPLY |REJECT | |

| |((CHECK ONE) | | |DEPENDENT LIFE | | | |

| |PLAN A | | | |STD BENEFIT | | | |

| |PLAN B | | | |LONG TERM DISB. | | | |

| | |

|DEPENDENT INFORMATION |

|DEPENDENT NAME |RELATIONSHIP |DATE OF BIRTH |SOCIAL SECURITY # |

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|GROUP LIFE BENEFICIARY |

|PRIMARY |CONTINGENT |

|FULL NAME |RELATIONSHIP |FULL NAME |RELATIONSHIP |

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|APPLICATION FOR GROUP ACCIDENT INSURANCE (HIGH LIMIT ACCIDENT) |

|24 Hour Accidental Death and Dismemberment Coverage | |

|( Reject |Principal Sum (Units of $1,000 only) |

|( Agent |$ ,000 | |

|( Spouse |$ ,000 | |

|( All Children (monthly premium is $.36 regardless of number) |$ ,000 | |

|( Pilot Coverage (subject to acceptable Special Aviation Data Sheet) |$ ,000 | |

| PRINT FULL NAME OF AGENT’S BENEFICIARY BELOW (EXAMPLE: JANE DOE, WIFE not MRS. JOHN DOE) |

| |

| (Last) (First) (MI) (Relationship to Agent) |

|OHIO REQUIRED STATEMENT – ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD |

|AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY |

|OF INSURANCE FRAUD. |

|I hereby apply for the Group Insurance for which I am or may become eligible under the Group Policies issued to the Policyholder by the Nationwide |

|Life Insurance |

|Company and/or the Nationwide Mutual Insurance Company, Columbus, Ohio, and authorize the Policyholder to deduct from my commissions, my contribution |

|to the cost |

|of the Group insurance. This authorization shall continue until revoked by the Policyholder. This application cancels and replaces all earlier |

|applications. |

| |

|Signature of Agent | |Date: | | |

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