Sentinel Advantage Variable Annuity
Dollar Cost Averaging Request
Annuitant's Name:
Contract No.:
Mail completed form to: Customer Relations - M330
A. Dollar Cost Averaging (DCA) Feature
Add
Cancel**
Change
Once each month, the total monthly transfer amount will be transferred from the Fidelity VIP Money Market Fund or the Enhanced Fixed Account
to the other sub-accounts as indicated below.
Not available with Portfolio Rebalancing. Only one DCA program may be operational at one time (either 1 or 2 below, but not both).
1.
I elect Dollar Cost Averaging from the Fidelity VIP Money Market Fund.
Complete Section B.
2.
I elect Dollar Cost Averaging from the Enhanced Fixed Account. (EFA)
a. Number of months
(6 or 12 months)
b. Amount to the Enhanced Fixed account: $
Complete Section B.
** Any value remaining in the EFA will be reallocated based on the current premium allocation in effect at the time of the request.
B. Dollar Cost Averaging Section
Total monthly transfer cannot be less than $100. If DCA from an EFA, based on the number of months selected above, the total monthly transfer
must equal 1/6 or 1/12 of the amount placed in the EFA. Any subsequent payments to be applied to the EFA(s) must be accompanied by a new form.
Sentinel
VPT Common Stock
VPT Mid Cap
VPT Small Company
VPT Balanced
VPT Bond
$
$
$
$
$
Alger
Capital Appreciation
Large Cap Growth
Small Cap Growth
$
$
$
AllianceBernstein
VPS Value
VPS Small/Mid Cap Value
VPS International Value
VPS International Growth
$
$
$
$
American Century
VP Income & Growth
VP Ultra
VP Value
VP International
VP Inflation Protection
$
$
$
$
$
Dreyfus
VIF Appreciation
Socially Responsible Growth
VIF Opportunistic Small Cap
VIF Quality Bond
$
$
$
$
9351(1114)
Cat. No. 47968
Deutsche
Small Mid Cap Value VIP
Small Cap Index VIP
Large Cap Value VIP
$
$
$
Fidelity
VIP Equity-Income
VIP Index 500
VIP Growth
VIP Contrafund
VIP Value Strategies
VIP Mid Cap
VIP Overseas
VIP Investment Grade Bond
VIP High Income
$
$
$
$
$
$
$
$
$
Franklin Templeton
Franklin Mutual Shares VIP
Franklin Small Cap Value VIP
Franklin Small-Mid Cap Growth VIP
Templeton Foreign VIP
Franklin Mutual Global Discovery VIP
Franklin U.S. Government Sec. VIP
Franklin Global Real Estate VIP
$
$
$
$
$
$
$
Invesco
V.I. Mid Cap Growth
V.I. Technology
V.I. Global Health Care
$
$
$
National Life Group® is a trade name of National Life Insurance Company (NLIC) and its affiliates.
National Life Variable Contracts distributed by Equity Services, Inc., Member FINRA/SIPC, Broker/Dealer Affiliate of NLIC.
Centralized Mailing Address: One National Life Drive, Montpelier, VT 05604 | P: 800-732-8939 | www.NationalLifeGroup.com
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Sentinel Advantage Variable Annuity Dollar Cost Averaging Request - Continued
J.P. Morgan
IT Small Cap Core
$
Neuberger Berman
AMT Large Cap Value
AMT Social Responsive
AMT Mid-Cap Growth
AMT Small Cap Growth
AMT Short Duration Bond
$
$
$
$
$
Oppenheimer
Main Street Small Cap/VA
Capital Income/VA
Global Strategic Income/VA
$
$
$
T. Rowe Price
Equity Income
Blue Chip Growth
Personal Strategy Balanced
Health Sciences
Owner's Signature/Date:
9351(1114)
Van Eck
VIP Emerging Markets
VIP Unconstrained Emerging
Markets Bond
VIP Global Hard Assets
Wells Fargo Advantage
VT Opportunity
VT Discovery
$
$
$
$
$
Other (as available)
$
$
Total Monthly Transfer
$
$
$
$
$
Telephone No.:
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