INDEPENDENT CONTRACTOR AGENT INSURANCE ENROLLMENT FORM / DATE ATTAINED CAREER STATUS
COMPLETE IN FULL (not valid without signature & date)
LAST NAME FIRST NAME MI ST# AGENT # / MARITAL STATUS
SINGLE / o
MARRIED / o
AGENT LIFE COV /
APPLY
/REJECT
/ DIVORCED / o(üCHECK ONE) / DEPENDENT LIFE / SEX / M o / F o
PLAN A / STD BENEFIT / DEPENDENT INFO
PLAN B / LONG TERM DISB. / CHILDREN / Y / N
DEPENDENT INFORMATION
DEPENDENT NAME / RELATIONSHIP / DATE OF BIRTH / SOCIAL SECURITY #
GROUP LIFE BENEFICIARY
PRIMARY / CONTINGENT
FULL NAME / RELATIONSHIP / FULL NAME / RELATIONSHIP
APPLICATION FOR GROUP ACCIDENT INSURANCE (HIGH LIMIT ACCIDENT)
24 Hour Accidental Death and Dismemberment Coverage
o Reject / Principal Sum (Units of $1,000 only)
o Agent / $ ,000
o Spouse / $ ,000
o All Children (monthly premium is $.36 regardless of number) / $ ,000
o 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: