Document:

Policy Specifications

    

    

    Policy Number [SPECIMEN]

    

    

    	
            Insured:

          	
            [JOHN DOE]

          	
            Issue Age and Sex:

          	
            [35] [MALE]

          
	 
	
            Owner:

          	
            [JOHN DOE]

          
	 
	
            Target Age

          	
            [65]

          
	 
	
            Initial Life Insurance Amount:

          	
            $[100,000]

          	
            Policy Date:

          	
            [SEPTEMBER 15, 2022]

          
	 	 	 	 
	
            Monthly Anniversary Day:

          	
            [15]

          	
            Date of Issue:

          	
            [SEPTEMBER 15, 2022]

          
	 
	
            Plan of Insurance:

          	
            INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ADJUSTABLE LIFE INSURANCE

          
	 	 
	
            Separate Account:

          	
            [Lincoln Life Flexible Premium Variable Life Account M]

          
	 	 
	
            Death Benefit Option:

          	
            2 (Increasing)

          
	 	 
	
            Death Benefit Option Change Period:

          	
            [11th] Policy Year and thereafter until the Insured’s Attained Age 121.

          

    

    

    	NOTE:	
            This Policy provides life insurance coverage to the death of the Insured if sufficient premiums are paid.  The duration of coverage will depend on
              the amount, timing, and frequency of premium payments, Persistency Bonus credited, Cost of Insurance, investment performance of the Separate Account, any loans or withdrawals and the cost of additional benefits.  The Planned Premium may need
              to be increased to keep this Policy and the coverage In Force.

          

    

    

    	
            Minimum Initial Premium Payment:

          	
            $[3,000.00].

          

    

    

    	
            Premium Payments:

          	
            Planned Premium Amount: $[3,000.00] [and increasing by [5.00]% in each Policy Year in Policy Year(s) [2] and thereafter until the Target Age.]

          
	 	
            Premiums payable until the Insured’s Attained Age 121.

            Premium payments after the Minimum Initial Premium may vary by frequency or amount subject to the Minimum Additional Premium Payment Amounts shown
              below.

          
	 
	
            Payment Mode:

          	
            [ANNUALLY]

          
	 
	
            Minimum Additional Premium Payment Amount:

          	
            We will not accept a premium payment of less than $[200.00] Annually, $[100.00] Semi-Annually, $[60.00] Quarterly, or $[15.00] Monthly.

          

    

    

    	
            Beneficiary:

          	
            [As named in the application for this Policy, unless later changed.]

          
	 	 
	
            Persistency Bonus Duration:

          	
            The later of a. or b., where:

            a. is Policy Years [30 and thereafter];

            b. is the Policy Year in which you change to Death Benefit Option 1 and all Policy Years thereafter.

          	 
	 	 
	
            Guaranteed Minimum Persistency Bonus Rate Credited to Sub-Accounts:

          	
            [0.01]% annual effective rate ([0.000833]% monthly).

          	 
	 	 

    

    

    
      
        

    

    Policy Specifications

    

    

    Policy Number [SPECIMEN]

    

    

    	
            Loan Information

          	 
	 	 
	
            Loan Amount:

          	
            Must not exceed [100.00]% of the Cash Value of this Policy as of the end of the Valuation Period ending on the Valuation Day on which we receive your
              Request.

          
	 	 
	
            Minimum Loan Repayment Amount:

          	
            $[25.00]

          

    

    

    	
            Loans

          	 	 
	 	 	 
	
            Loan Interest Rate Charged:

          	
            [0.25]% annual effective rate in Policy Years 1 and thereafter.

          	 
	 	 
	
            Loan Account Credited Interest Rate:

          	
            [0.25]% annual effective rate ([0.000684]% daily) in Policy Years 1 and thereafter.

          	 
	 	 
	
            Withdrawals

          	 
	 	 
	
            Amount of Withdrawals:

          	
            Must not exceed [100.00]% of the Cash Value of this Policy as of the end of the Valuation Period ending on the Valuation Day on which we receive your
              Request.

          
	 	 
	
            Transfers

          	 	 
	 	 	 
	
            Minimum Transfer Amount:

          	
            $[50.00] or the entire value of the Sub-Account being transferred, whichever is less.

          	 
	 	 	 
	
            Minimum Remaining Value of the Sub-Account(s) After a Transfer:

          	
            $100.00 unless the entire value of the Sub-Account(s) is being transferred.

          	 
	 	 	 

    
      
        

    

    Policy Specifications

    

    

    Policy Number [SPECIMEN]

    

    

    Riders and Benefits Charges

    

    

    [No riders/benefits have been elected.]

    
      
        

    

    Policy Specifications

    

    

    Policy Number [SPECIMEN]

    

    

    Table of Expense Charges and Fees

    

    

    The following expenses and fees are charged under this Policy:

    

    

    Cost of Insurance

    See the “Cost of Insurance” provision.

    

    

    Mortality and Expense Risk ("M&E") Charge Rate

    	
            [0.60]% annually ([0.05]% monthly) in Policy Year(s) [1-20].

          

    

    

    Transfer Fee

    $[25.00] per transfer request for each transfer request in excess of [24] during any Policy Year.

    

    

    
      
        

    

    Policy Specifications

    

    

    Policy Number [SPECIMEN]

    

    

    Table of Monthly Administrative Fees

    

    

    This Policy’s Monthly
      Administrative Fee will be equal to (a) multiplied by (b), where:

    
      	
              (a)

            	
              is the applicable Monthly Administrative Fee shown below;

            

    

    
      	
              (b)

            	
              is the Initial Life Insurance Amount, divided by 1,000.

            

    

    The Monthly Administrative Fees per $1,000 of Initial Life Insurance Amount vary by the Insured’s sex, Target Age, and
      Issue Age.

    

    

    	
            Policy

            Year

          	 	
            Monthly

            Rate

          	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 
	
            [1

          	 	
            0.12888

          	 	 	 	 	 	 	 	 
	
            2

          	 	
            0.11803

          	 	 	 	 	 	 	 	 
	
            3

          	 	
            0.10551

          	 	 	 	 	 	 	 	 
	
            4

          	 	
            0.09382

          	 	 	 	 	 	 	 	 
	
            5

          	 	
            0.08129

          	 	 	 	 	 	 	 	 
	
            6

          	 	
            0.06876

          	 	 	 	 	 	 	 	 
	
            7

          	 	
            0.05707

          	 	 	 	 	 	 	 	 
	
            8

          	 	
            0.04704

          	 	 	 	 	 	 	 	 
	
            9

          	 	
            0.04287

          	 	 	 	 	 	 	 	 
	
            10

          	 	
            0.03702

          	 	 	 	 	 	 	 	 
	
            11

          	 	
            0.03200

          	 	 	 	 	 	 	 	 
	
            12

          	 	
            0.02615

          	 	 	 	 	 	 	 	 
	
            13

          	 	
            0.02030

          	 	 	 	 	 	 	 	 
	
            14

          	 	
            0.01529

          	 	 	 	 	 	 	 	 
	
            15

          	 	
            0.00693

          	 	 	 	 	 	 	 	 
	
            16

          	 	
            0.00000]

          	 	 	 	 	 	 	 	 
	
            and later

          	 	 	 	 	 	 	 	 	 	 

    

    

    
      
        

    

    Policy Specifications

    

    

    Policy Number [SPECIMEN]

    

    

    Table of Guaranteed Maximum Cost of Insurance Rates

    

    

    The monthly Cost of Insurance rates per $1,000 of net amount at risk vary by the Insured’s sex, Attained Age, and the Policy Year but will
      not exceed the rates shown in the table below in accordance with the [Ultimate 2017 CSO Male/Female, Unismoke, age last birthday] mortality table.

    

    

    	
            Policy

            Year

          	 	
            Monthly

            Rate

          	 	
            Policy

            Year

          	 	
            Monthly

            Rate

          	 	
            Policy

            Year

          	 	
            Monthly

            Rate

          
	 	 	 	 	 	 	 	 	 	 	 
	
            [1

          	 	
            0.11759

          	 	
            31

          	 	
            0.93735

          	 	
            61

          	 	
            24.81823

          
	
            2

          	 	
            0.12844

          	 	
            32

          	 	
            1.03189

          	 	
            62

          	 	
            26.95932

          
	
            3

          	 	
            0.14096

          	 	
            33

          	 	
            1.13330

          	 	
            63

          	 	
            29.34796

          
	
            4

          	 	
            0.15265

          	 	
            34

          	 	
            1.24502

          	 	
            64

          	 	
            32.02278

          
	
            5

          	 	
            0.16518

          	 	
            35

          	 	
            1.37386

          	 	
            65

          	 	
            34.95613

          
	
            6

          	 	
            0.17771

          	 	
            36

          	 	
            1.52416

          	 	
            66

          	 	
            38.01118

          
	
            7

          	 	
            0.18940

          	 	
            37

          	 	
            1.70201

          	 	
            67

          	 	
            41.06958

          
	
            8

          	 	
            0.19942

          	 	
            38

          	 	
            1.90932

          	 	
            68

          	 	
            44.21871

          
	
            9

          	 	
            0.20360

          	 	
            39

          	 	
            2.14460

          	 	
            69

          	 	
            47.40348

          
	
            10

          	 	
            0.20945

          	 	
            40

          	 	
            2.40725

          	 	
            70

          	 	
            50.56253

          
	
            11

          	 	
            0.21447

          	 	
            41

          	 	
            2.69323

          	 	
            71

          	 	
            53.62137

          
	
            12

          	 	
            0.22032

          	 	
            42

          	 	
            3.00193

          	 	
            72

          	 	
            57.08094

          
	
            13

          	 	
            0.22617

          	 	
            43

          	 	
            3.33711

          	 	
            73

          	 	
            61.67895

          
	
            14

          	 	
            0.23118

          	 	
            44

          	 	
            3.70959

          	 	
            74

          	 	
            66.81366

          
	
            15

          	 	
            0.23954

          	 	
            45

          	 	
            4.13221

          	 	
            75

          	 	
            72.58700

          
	
            16

          	 	
            0.24647

          	 	
            46

          	 	
            4.61819

          	 	
            76

          	 	
            79.13061

          
	
            17

          	 	
            0.24647

          	 	
            47

          	 	
            5.16782

          	 	
            77

          	 	
            83.33333

          
	
            18

          	 	
            0.24647

          	 	
            48

          	 	
            5.81657

          	 	
            78

          	 	
            83.33333

          
	
            19

          	 	
            0.24647

          	 	
            49

          	 	
            6.59415

          	 	
            79

          	 	
            83.33333

          
	
            20

          	 	
            0.24647

          	 	
            50

          	 	
            7.49708

          	 	
            80

          	 	
            83.33333

          
	
            21

          	 	
            0.24647

          	 	
            51

          	 	
            8.54642

          	 	
            81

          	 	
            83.33333

          
	
            22

          	 	
            0.24647

          	 	
            52

          	 	
            9.75657

          	 	
            82

          	 	
            83.33333

          
	
            23

          	 	
            0.24647

          	 	
            53

          	 	
            11.13585

          	 	
            83

          	 	
            83.33333

          
	
            24

          	 	
            0.24647

          	 	
            54

          	 	
            12.66556

          	 	
            84

          	 	
            83.33333

          
	
            25

          	 	
            0.24647

          	 	
            55

          	 	
            14.31808

          	 	
            85

          	 	
            83.33333

          
	
            26

          	 	
            0.24647

          	 	
            56

          	 	
            16.06273

          	 	
            86

          	 	
            83.33333

          
	
            27

          	 	
            0.24647

          	 	
            57

          	 	
            17.84931

          	 	
            87 and

          	 	
            0.00000]

          
	
            28

          	 	
            0.24647

          	 	
            58

          	 	
            19.64970

          	 	
            later

          	 	 
	
            29

          	 	
            0.24647

          	 	
            59

          	 	
            21.41442

          	 	 	 	 
	
            30

          	 	
            0.24647

          	 	
            60

          	 	
            23.05701

          	 	 	 	 

    

    

    
      
        

    

    Policy Specifications

    

    

    Policy Number [SPECIMEN]

    

    

    Corridor Percentages Table

    

    

    Death Benefit Qualification Test: Guideline Premium Test

    

    

    See the “Death Benefit Proceeds” provision and “Income Tax on Death Benefits” provision for an explanation of how this table will be used.

    

    

    	
            Insured’s Attained

            Age

          	
            Corridor

            Percentage

          	 	
            Insured’s Attained

            Age

          	
            Corridor

            Percentage

          
	 	 	 	 	 	 
	 	
            [35-40

          	
            250%

          	 	
            60

          	
            130%

          
	 	
            41

          	
            243%

          	 	
            61

          	
            128%

          
	 	
            42

          	
            236%

          	 	
            62

          	
            126%

          
	 	
            43

          	
            229%

          	 	
            63

          	
            124%

          
	 	
            44

          	
            222%

          	 	
            64

          	
            122%

          
	 	 	 	 	 	 
	 	
            45

          	
            215%

          	 	
            65

          	
            120%

          
	 	
            46

          	
            209%

          	 	
            66

          	
            119%

          
	 	
            47

          	
            203%

          	 	
            67

          	
            118%

          
	 	
            48

          	
            197%

          	 	
            68

          	
            117%

          
	 	
            49

          	
            191%

          	 	
            69

          	
            116%

          
	 	 	 	 	 	 
	 	
            50

          	
            185%

          	 	
            70

          	
            115%

          
	 	
            51

          	
            178%

          	 	
            71

          	
            113%

          
	 	
            52

          	
            171%

          	 	
            72

          	
            111%

          
	 	
            53

          	
            164%

          	 	
            73

          	
            109%

          
	 	
            54

          	
            157%

          	 	
            74

          	
            107%

          
	 	 	 	 	 	 
	 	
            55

          	
            150%

          	 	
            75-90

          	
            105%

          
	 	
            56

          	
            146%

          	 	
            91

          	
            104%

          
	 	
            57

          	
            142%

          	 	
            92

          	
            103%

          
	 	
            58

          	
            138%

          	 	
            93

          	
            102%

          
	 	
            59

          	
            134%

          	 	
            94

          	
            101%

          
	 	 	 	 	 	 
	 	 	 	 	
            95

          	
            100%]

          
	 	 	 	 	
            and later

          	 

    
      
        

    

    Policy Specifications

    

    

    Policy Number [SPECIMEN]

    

    

    	
            No-Lapse Provision:

          	
            No-Lapse Premium: $[24.67] monthly

            No-Lapse Period: [30] Policy Years

          
	 
	
            No-Lapse Test: The No-Lapse Test is met if:

          
	
            (a) on each Monthly Anniversary Day, you have paid premium equal to [12] monthly No-Lapse Premiums within the past [15] Policy Months; and

            (b) (1) is at least equal to (2), where:

            (1) is an amount equal to the sum of all premium payments less any withdrawals, less any Debt; and

            (2) is an amount equal to the sum of the corresponding No-Lapse Premiums above due since the Policy Date.

          

    

    

    	
            Overloan Protection

          
	 	 
	
            Residual Life Insurance Amount Percentage:

          	
            [1.00]%

          
	 	 
	
            Percentage of Accumulation Value:

          	
            100.00%

          

    

    

    
      
        

    

    (This Page Left Blank Intentionally)Lincoln LifeGoalsSM Application for Individual Life Insurance

      The Lincoln National Life Insurance Company PO Box 21008, Greensboro, NC 27420-1008 (hereinafter referred to as the “Company”)

      

      

      Request For:

      ☐ New Application for Insurance: Complete Application in its entirety; sign and date.

      ☐ Reinstatement: Provide Policy Number; Complete Questions 1 – 11 and 26 – 41; sign and
        date.

      Policy Number:  

      Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense
        and

      subject to penalties under state law.

      

      

      Proposed Insured Personal Details

      	
              1.

            	
              Legal Name:  

            

      	
              2.

            	
              Sex:    ☐ Male ☐ Female3. Date of
                    Birth: 

            

      4.  SSN:  5. Place of Birth:  

      	
              6.

            	
              Are you a citizen of the United States or a valid green card holder? ☐ Y☐ N

            

      	
              7.

            	
              Do you have a Driver’s License? ☐ Y☐ N

            

      If “Yes,” a. Driver’s License Number:  b. License State:  

      If “No,” c. Why don’t you have a license?  

      	
              8.

            	
              Physical Home Address:  

            

      	
              9.

            	
              a. Cell Phone Number: b. Land Line Number: 

            

      	
              10.

            	
              Email:  

            

      	
              11.

            	
              What is your total annual income from all sources?  

            

      

      

      The Policy

      	
              12.

            	
              Product: 13. Life Insurance Amount: $ 

            

      	
              14.

            	
              Death Benefit Option:

            

      Target Age Selection (For New Applications only)

      I hereby select the following Target Age ; at which time I will be able to confirm my plan with The Lincoln National Life
          Insurance Company to change the Policy Death Benefit Option from Option 2 – Increase by Cash Value to Option 1 – Level, which may also result in an adjustment to the Policy Life Insurance Amount.

      

      

      The Policy Owner (If other than Proposed Insured)

      	
              15.

            	
              a. Owner Name:  

            

      Trustee/Officer (If applicable):  

      b. Address:  

      c. Date of Birth/Trust Date:  d. SSN/TIN:  

      e. Cell Phone Number:  f. Land Line Number:  

      g. Country of citizenship:  h. Relationship to Proposed Insured:  

      i. Owner’s Email:  

    

    

    

    Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.

    Page 1 of 6

    

    

    
      
        

    

    

    

    

    

    

    

    Beneficiaries (Unless otherwise stated in Number 19 “Special Instructions,” if multiple beneficiaries are named in a

    class (Primary, Contingent), the proceeds are to be paid equally to the survivor or survivors in
      the class, if any.)

    
      	
              16.

            	
              a. Primary Beneficiary Name:  

            

    

    Trustee/Officer (If applicable):  

    b. Address:  

    c. Relationship to Proposed Insured: d.  Date of Birth/Trust Date:  

    e. SSN/TIN: f. Phone Number:  

    g. Beneficiary’s Email:  

    

    

    
      
        	17.	a. ☐ Primary  ☐ Contingent Beneficiary Name: 	

              

      

    

    Trustee/Officer (If applicable):  

    b. Address:  

    c. Relationship to Proposed Insured: d.  Date of Birth/Trust Date:  

    e. SSN/TIN: f. Phone Number:  

    g. Beneficiary’s Email:  

    

    

    
      
        	18.	a. ☐ Primary  ☐ Contingent Beneficiary Name: 	

              

      

    

    Trustee/Officer (If applicable):  

    b. Address:  

    c. Relationship to Proposed Insured: d.  Date of Birth/Trust Date:  

    e. SSN/TIN: f. Phone Number:  

    g. Beneficiary’s Email:  

    

    

    
      	
              19.

            	
              Special Instructions (If
                  beneficiary proceeds are not to be paid equally it is indicated here.)

            

    

    

    

    

    

    Premium and Billing Information

    
      	
              20.

            	
              Planned Premium Amount: $ 

            

    

    
      	
              21.

            	
              How often do you plan to pay premiums? ☐ Annual EFT☐ Semi-Annual EFT☐ Quarterly EFT☐ Monthly EFT

            

    

    
      	
              22.

            	
              What is the source of premium?:  

            

    

    
      	
              23.

            	
              Will the premiums for this Policy be paid, advanced, financed or otherwise funded by any other person or entity other than you
                (Proposed Insured/Owner), your spouse , domestic partner, immediate family member or employer?☐ Yes☐ No

            

    

    
      	
              24.

            	
              Who will be paying the premium for this Policy?

            

    

    
      	
              a.

            	
              Payor Name:  

            

    

    
      	
              b.

            	
              Address:  

            

    

    
      	
              c.

            	
              SSN/TIN: d. Relationship to Proposed Insured: 

            

    

    

    

    Protection Against Unintended Lapse (For additional protection against unintended lapse, you have the right to designate one person who will receive lapse and non-payment of
        premium notices. The designated person should be an individual other than your Agent/Financial Professional who will receive these notices automatically.)

    
      	
              25.

            	
              I, the Applicant/Owner, understand that I have the right to designate at least one person other than myself to receive notice
                of lapse or termination of this insurance policy for non-payment of premium. I also understand that I will be given the opportunity to change this written designation at any time.

            

    

    If I choose to designate an additional person to receive lapse and non-payment of premium notices
      they are listed below. Name:  Mailing Address:   Phone Number:  

    
      
        

    

    

    

    

    

    

    

    Existing Insurance and Replacement Information

    
      	
              26.

            	
              Do you have any existing life insurance policies or annuity contracts with The Lincoln National Life Insurance Company or any other
                company?

            

    

    
      	
              27.

            	
              With the purchase of this Lincoln LifeGoalsSM coverage will any life insurance policy or annuity contract be replaced,
                lapsed, surrendered, assigned, have benefits reduced or premium payments stopped; or have funds used or borrowed to pay premiums due?

            

    

    
      	
              28.

            	
              If answer to question 27 is "Yes," replacement details are provided below.

            

    

    Issue Date 1035

    Company Coverage Amount Policy Number (mm/dd/yy) Exchange?

    $         ☐ Y ☐ N

    $         ☐ Y ☐ N

    $         ☐ Y ☐ N

    
      	
              29.

            	
              Including this Lincoln LifeGoalsSM policy, how much total life insurance coverage will you have?

            

    

    (Exclude any life insurance that might be provided by your employer.) 

    
      	
              30.

            	
              Did you have any prior life insurance application that resulted in a rated or declined decision? ☐ Y ☐ N

            

    

    

    

    Proposed Insured Lifestyle

    
      	
              31.

            	
              Do you plan to participate in any of the following activities within the next two years?☐ Y ☐ N

            

    

    
      	
              •

            	
              Flying homebuilt, kit-built, vintage or experimental planes

            

    

    
      	
              •

            	
              Private piloting with any flying outside of the United States

            

    

    
      	
              •

            	
              Scuba diving to depths greater than 100 feet, except for certification purposes

            

    

    
      	
              •

            	
              Mountain climbing, outdoor rock climbing that requires ropes and harnesses, or outdoor

            

    

    rock freestyle (free) climbing

    
      	
              •

            	
              High performance auto, motorcycle or boat racing requiring specialized fuel

            

    

    
      	
              •

            	
              Rodeo sports; aerial sports; BASE Jumping or wingsuit flying

            

    

    
      	
              •

            	
              Free-fall or non-tandem skydiving; bungee jumping; or heli-skiing

            

    

    
      	
              32.

            	
              Do you plan to travel or reside outside of the United States for more than 30 days in the next 12 months?☐ Y ☐ N

            

    

    
      	
              33.

            	
              In the past three years, have you been convicted of, three or more moving violations; driving under

            

    

    the influence of alcohol or drugs; or had your driver’s license suspended, restricted, or revoked

    due to any moving violation? ☐ Y ☐
        N

    
      	
              34.

            	
              Have you ever been convicted of, or are you awaiting trial for a felony? ☐
                  Y ☐ N

            

    

    

    

    Proposed Insured Health History

    
      	
              35.

            	
              Do you have a Body Mass index greater than 37 kg/m2?

            

    

    
      	
              36.

            	
              Do you currently use, or within the past 12 months have you used, cigarettes, e-cigarettes, vaping products, or herbal cigarettes?

            

    

    
      	
              37.

            	
              In the past 10 years, have you been diagnosed by, or been treated by a licensed medical professional for any of the following
                conditions:

            

    

    
      	
              a.

            	
              Chronic pain requiring therapy with any opioid (narcotic) medications

            

    

    prescribed six or more times per year? ☐Y ☐N

    
      	
              b.

            	
              Coronary or vascular disease including history of heart attack, stroke,

            

    

    cardiomyopathy, abnormal heart rhythm, aortic valve disease or surgery,

    mitral valve stenosis or surgery, or congenital heart defects? ☐Y ☐N

    
      	
              c.

            	
              Type I or Type II diabetes?

            

    

    
      	
              d.

            	
              Chronic obstructive pulmonary disease (COPD), chronic bronchitis, ☐Y ☐N

            

    

    emphysema, or cystic fibrosis?

    
      	
              e.

            	
              Alzheimer’ disease, dementia or cognitive impairment? ☐Y ☐N

            

    

    
      	
              f.

            	
              Huntington’s disease or polycystic kidney disease? ☐Y ☐N

            

    

    
      	
              g.

            	
              Chronic hepatitis B infection, untreated hepatitis C infection,

            

    

    cirrhosis of the liver, Crohn’s disease, or ulcerative colitis? ☐Y ☐N

    
      	
              h.

            	
              Chronic kidney disease or kidney failure? ☐Y ☐N

            

    

    
      	
              i.

            	
              Bipolar disorder, major depressive disorder, psychosis, or schizophrenia?☐Y ☐N

            

    

    
      	
              j.

            	
              Multiple sclerosis, Parkinson’s disease, amyotrophic lateral sclerosis (ALS),☐Y ☐N

            

    

    or degenerative neurological disease?

    
      	
              k.

            	
              Systemic lupus erythematosus, rheumatoid arthritis, Marfan syndrome, ☐Y
                  ☐N

            

    

    scleroderma, vasculitis, or polymyositis?

    
      	
              l.

            	
              Organ or bone marrow transplant recipient? ☐Y ☐N

            

    

    
      	
              38.

            	
              Have you ever tested positive for the Human Immunodeficiency Virus (HIV) or been diagnosed as having

            

    

     or been treated by a licensed medical professional for Acquired Immune Deficiency Syndrome (AIDS) or

     an AIDS-related condition? ☐Y ☐N

    
      	
              39.

            	
              Within the past five years have you been diagnosed by, or been treated by a licensed medical professional

            

    

     for any cancer, excluding non-melanoma skin cancers? ☐Y ☐N

    
      	
              40.

            	
              Have you received treatment from a licensed medical professional for alcohol or substance abuse within

            

    

    the past 10 years; or within the past five years have you used cocaine or non-prescription stimulants,

    depressants, hallucinogens, narcotics, inhalants, or other illegal, restricted or controlled substances (excluding marijuana)? ☐Y ☐N

    
      	
              41.

            	
              Have you been advised within the past five years by a licensed medical professional to have any medical

            

    

    procedure or surgery that has not been completed? ☐Y ☐N

    Suitability

    
      	
              1.

            	
              Have you, the Proposed Insured and Owner, received a current Prospectus or Summary Prospectus for

            

    

    the Policy applied for and have you had sufficient time to review it? ☐Y ☐N

    
      	
              2.

            	
              Do you understand that the amount and duration of the death benefit may increase or decrease depending

            

    

    on the investment performance of funds in the Separate Account? ☐Y ☐N

    
      	
              3.

            	
              Do you understand that the cash values may increase or decrease depending on the investment performance

            

    

    of the funds held in the Separate Account? ☐Y ☐N

    
      	
              4.

            	
              With this in mind, do you believe that the Policy applied for is in accord with your insurance objective and

            

    

     your anticipated financial needs? ☐Y ☐N

    CASH VALUES ARE NOT GUARANTEED AND MAY INCREASE OR DECREASE IN ACCORDANCE
      WITH THE EXPERIENCE OF THE SEPARATE ACCOUNT. THE DEATH BENEFIT MAY BE VARIABLE OR FIXED UNDER SPECIFIED CONDITIONS.

    Refer to the contract for information on any no-lapse guarantee that may be provided.

    

    

    Service Office Endorsements (For Company Use Only. We will attach additional documentation as needed.)

    

    

    Agreement and Acknowledgement

    I, the Owner, certify that the tax identification or social security number as provided by me is
      correct. I also certify that I am not subject to backup withholding.

    The Undersigned declares that:

    
      	
              1.

            	
              This Application consists of: a) Application for Individual Life Insurance; b) any amendments to the application(s) attached
                thereto; and c) any supplements, all of which are required by the Company for the plan, amount and benefits applied for. The Application, as defined above, and the recorded answers contained therein, will be bound with the Policy at issue.

            

    

    
      	
              2.

            	
              I agree that insurance will take effect under the Policy only when: 1) the Policy has been delivered to and accepted by me; 2)
                the initial premium has been paid in full during the lifetime of the Proposed Insured; and 3) the Proposed Insured remains in the same state of health and insurability as described in each part of the application at the time conditions 1)
                and 2) are met.

            

    

    
      	
              3.

            	
              No agent, broker or medical examiner has the authority to make or modify any Company contract or to waive any of the Company’s
                requirements.

            

    

    
      	
              4.

            	
              Corrections, additions or changes to this Application may be made by the Company. Any such changes will be shown under “Service
                Office Endorsements”. Acceptance of a policy issued with such changes will constitute acceptance of the changes. No change will be made in classification (including age at issue), plan, amount, or benefits unless agreed to in writing by the
                Applicant.

            

    

    
      
        

    

    

    

    
      	
              5.

            	
              I have been advised to consult with my own tax advisors regarding the tax effects inherent in the plan of insurance for which
                I am applying.

            

    

    
      	
              6.

            	
              Any reinstated coverage will not be in effect unless and until (a) all premiums and charges have been paid to and accepted by
                the Company; (b) the requested changes have been accepted by the Company; and (c) statements on this form and on any other application submitted as a part of this request are correct at the time of such payments and approval. Blank spaces
                in questions for the Owner and Beneficiary indicate there is no change from the previous designation.

            

    

    
      	
              7.

            	
              This application shall amend and be a part of the original application and the Policy. Upon reinstatement, the period of
                contestability with respect to statements made in this application shall begin anew as of the date the new coverage is made to be in effect by the Company.

            

    

    
      	
              8.

            	
              I HAVE READ, or have had read to me, the completed Application for Individual Life Insurance before signing below. All
                statements and answers in this Application for Individual Life Insurance are correctly recorded, and are full, complete and true to the best of my knowledge and belief. I confirm that upon receipt of the Policy, I will review the answers
                recorded on the Application, as defined in number 1 above. I will notify the Company immediately if any information in the Application is incorrect. Caution: I understand that if any answers on this Application are incorrect or untrue, the
                Company may have the right to deny benefits or rescind coverage under the Policy and any riders attached to it.

            

    

    

    

    Fraud Notice

    Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal
      offense and subject to penalties under state law.

    

    

    Authorization

    I, the Proposed Insured, authorize any medical professional, hospital or other medical
      institution, Pharmacy Benefit Manager, insurer, MIB, Inc., or any other person or organization that has any records or knowledge of me or my physical or mental health or insurability to disclose that information to the Company, its reinsurers, or any
      other party acting on the Company’s behalf. I authorize the Company or its reinsurer to make a brief report of my protected health information to MIB, Inc. I authorize the Company to disclose information related to my insurability to other insurers
      to whom I may apply for coverage.

    Once this authorization is signed it shall be valid for 24 months or the time limit, if any, as
      permitted by applicable law in the state where the Policy is delivered or issued for delivery. A photographic copy of this authorization shall be as valid as the original. I understand that I may revoke this authorization at any time by written
      notification to the Company; however, any action taken prior to notification will not be affected.

    The purpose of this authorization is to allow the Company to determine eligibility for life
      coverage or a claim for benefits under a life policy.

    The undersigned declares that:

    I acknowledge receipt of the Privacy Practices Notice and the Important Notice.

    

    

    Signatory Section

    Signed in:   

    (State) Date (mm/dd/yyyy)

    

    

    

    

    

    

    

    

    	
            Signature of Proposed Insured

          	 	 
	
            Signature of Applicant/Owner/Trustee

            (If other than Proposed Insured)

          	 	
            Signature of Applicant/Owner/Trustee

            (If other than Proposed Insured)

          

    
      
        

    

    

    

    

    

    

    

    To Be Completed By Agent Only

    
      	
              (i)

            	
              Does the applicant have any existing life insurance policies or annuities? ☐ Y  ☐ N

            

    

    
      	
              (ii)

            	
              Do you know or have you any reason to believe that replacement of insurance is involved? ☐ Y  ☐ N

            

    

    If a replacement is involved, I certify that only company approved sales materials were used in this sale and that
      copies of

    all sales materials were left with the applicant.

    I declare that I have accurately answered all questions contained in this section.

    I declare that I have provided the Proposed Insured/Owner with the Important Notice and Privacy Practices Notice.

    

    

    

    

    

    

    

    

    	
            Signature of Licensed Agent, Broker or Registered Representative

          	 	
            Printed Name of Licensed Agent, Broker or Registered Representative

          

    

    

    I have reviewed the Application, Supplements, New Account Form and allocation forms and find the transaction suitable.

    

    

    

    

    

    

    

    

    	
            Signature of Registered Principal of Broker/Dealer

          	 	
            Printed Name of Registered Principal of Broker/Dealer

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