Contract Change Request and Medical Questionnaire

1 APO-1270-R11/2013 Contract Change Request and Medical Questionnaire Mail to: Nationwide life insurance company and Nationwide life and Annuity insurance company Individual Annuities, Box 182021, Columbus, Ohio, 43218-2021, 1-800-848-6331, Fax to: 1-888-634-4472 Page 1 of 5 Supplemental information MUST be completed for all of the following Owner Information (Please print.) All fields in this section are Change of Annuitant (Annuitant changes are not permitted on existing contracts with the Option.) Must include completed New Business Application and completed Medical Proposed Primary AnnuitantAnnuitant First/Last Name: Relationship to current Contract Owner: Date of Birth: State of Birth: Soc.

2 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 Proposed Contingent Annuitant/Co-Annuitant (If permitted.) Check one box only: Contingent Annuitant Co-AnnuitantAnnuitant First/Last Name: Relationship to current Contract Owner: Date of Birth: State of Birth: Soc.

3 Sec. No. Address: City/State/ZIP: Telephone Number: ( ) E-mail Address: 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-R11/2013 Contract Change Request and Medical QuestionnairePage 2 of 53. 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 ( ) Where permitted under law, if the Contract owner is changed or the Contract is assigned on a Nationwide DestinationSM B ( ), Nationwide DestinationSM L ( ), Nationwide DestinationSM EV ( ), Nationwide DestinationSM Navigator ( ), Nationwide DestinationSM All American Gold ( ), Waddell & Reed Advisors Select Preferred AnnuitySM ( ) 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 ( )

4 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 ( 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 ( the benefits may continue during the temporary assignment period and not terminate until the Contract is actually surrendered)3a.

5 New Primary OwnerOwner First/Last Name: Relationship to current Contract Owner: Date of Birth: Soc. Sec. No. or Tax ID: Address: City/State/ZIP: Telephone Number: ( ) E-mail Address: 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: Relationship to current Contract Owner: Date of Birth: Soc. Sec. No. or Tax ID: Address: City/State/ZIP: Telephone Number: ( ) E-mail Address: 4.

6 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 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.

7 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 Change Beneficiary Designation Allocation to all Primary Beneficiaries must equal 100%. Fractional percentages ( 1/3 or ) will not be New Primary Beneficiaries Pay all Primary Beneficiaries equallyLegal First Name: MI: Last Name: Relationship to Annuitant: Allocation (whole % only): %Social Security Number: Sex: M F Date of Birth: Address: City/State/ZIP: Telephone Number: ( ) E-mail Address: 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: Telephone Number: ( ) E-mail Address: 6b.

8 Contingent Beneficiaries Pay all Contingent Beneficiaries equallyLegal First Name: MI: Last Name: Relationship to Annuitant: Allocation (whole % only): %Social Security Number: Sex: M F Date of Birth: Address: City/State/ZIP: Telephone Number: ( ) E-mail Address: 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: Telephone Number: ( ) E-mail Address: Contract Change Request and Medical QuestionnairePage 3 of 5 APO-1270-R11/20137. 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.

9 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 Signatures Required for Any changes in the previous s Name: Date: Owner s Signature: X Joint Owner s Name: Date: Joint Owner s Signature: XNew Owner s Name: Date: New Owner s Signature: XNew Joint Owner s Name: Date: New Joint Owner s Signature: X9. Application Supplement Use this form to provide information for a new business application or if you have requested an annuitant Change on the preceding Medical Questionnaire Annuitant Co-Annuitant YES NO YES NO1.

10 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?