UNIVERSAL LIFE POLICY MAINTENANCE FORM DEFERRED COMPENSATION PLAN

SECTION 1

UNIVERSAL LIFE POLICY MAINTENANCE FORM DEFERRED COMPENSATION PLAN

Entity Number ______________________________________ Social Security Number

Entity Name __________________________________________________________ Policy Number ______________________

Name

Last

First

MI

Address

Number & Street

Additional Mailing Information

--

City

Home

_

_

Phone

Work Phone

State

Zip Code

_

_

Ext. ________________

NOTE: Changes in Sections 2 & 3 are contingent upon the life company?s approval.

SECTION 2 ? PLAN CHANGES

Check the appropriate box:

r Change from Plan 1 to Plan 2 r Change from Plan 2 to Plan 1

Yes, I have been advised and understand the change of the life plan and how it will affect my death benefit.____________________

(Initial)

SECTION 3 ? SMOKER STATUS CHANGE

If you have not used tobacco in any form in the last twelve months initial the appropriate option.

Medical verification at company expense will be required ? a PortaMedic representative will contact you.

Initial Appropriate Option

____ Decrease my Premium, Death Benefit remains the same (Participation Agreement required) ____ Increase my Death Benefit/Premiums remain the same (minimum increase $10,000 & Life application required)

SECTION 4 ? CANCELLATIONS (Check the appropriate box)

Separation from Service

Actively Employed

Separation from Service Date: ________________________________

Employer Signature: ________________________________________

x

x

H

xH

H

Cancel Life

Cancel Life

Use Cash Value Stop deferral

Coverage:

Coverage:

to obtain Single flow and allow

Refund Cash Refund

Premium

cash surrender

Surrender Value Surrender Value Paid-up Policy value to keep

to Annuity

to the

policy in force

Participant

until value is

exhausted

Cancel Life

Use Cash Value Stop deferral

Coverage:

to obtain Single flow and allow

Refund Cash Premium

cash surrender

Surrender Value Paid-up Policy value to keep

to Annuity

policy in force

until value is

exhausted

r

r

r

r

r

r

r

x Death benefit terminated

H On-going deferrals will be applied and based on current annuity allocation

SECTION 5 ? TRANSFER TO DIRECT PAY

Separation from Service Date: ______________ Signature of Employer: ____________________________________________

r Convert ownership of policy from entity to me. (Any cash surrender value is subject to federal income tax as required by the Internal Revenue Code.)

r Transfer the cash surrender value to annuity, amount of Death Benefit will decrease by the amount of transfer.

Billing Mode: r Monthly Bank Draft r Quarterly

r Semi-Annual

r Annual

Beneficiary Information: Name: ________________________________ Relationship: ________________ Date of Birth: ________

SSN: ________________________ Address: ____________________________________________________________________

NOTE: This change in beneficiary applies to universal life only and will not affect your other beneficiary designations.

I have read and understand the proposed change(s). I hereby request and understand the effective date(s) of such changes is/are contingent upon acceptance by the company.

Participant Signature __________________________________________________________ Date ______________________

NRS Representative __________________________________________________________ Date ______________________

Original ? Life Insurance Company 3 Copy 1 ? NRS 3 Copy 2 ? Participant Nationwide Retirement Solutions 3 PO Box 182797 3 Columbus, OH 43218-2797 3 1-866-827-NMEX(6639) 3 DC-4070-0903

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