This application is to: John Hancock Life Insurance Company or [LOGO]
Financial Services
P.O. Box 111, Boston, Massachusetts 02117
which will sometimes hereinafter be referred to as "the Company" and "John Hancock".
If applicable, this application is part of the case applied for in Master Application Number ______________
Part A Statements to the Company's Agent
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A. PROPOSED INSURED
1. Name of Proposed Insured (please print): 10. Address ______________________________________________
STREET ADDRESS
First________________________________________ MI __________ _______________________________________________________
CITY STATE ZIP
Last _______________________________________________________ 11. Home Phone (______)______-_______
2. Sex [_] Male [_] Female
12. Work Phone (______)______-_______
3. Date of Birth ____ / ____ / ____
Fax Number(______)______-_______
4. Place of Birth _____________________________________________ 13. Best time and place for Underwriting to call (in Proposed
STATE COUNTRY, IF NOT U.S.A. Insured's local time zone) ____________________________
5. Soc. Sec. Number ______-___-______
14 . Has the Proposed Insured smoked cigarettes or used any
6. Height _______ ft. _____ in. 7. Weight _________ lbs. other tobacco product, i.e., cigars, pipes, snuff, chewing
tobacco, etc., in the past 12 months.
8. Occupation _________________________________________________
[_] Yes [_] No
9. Drivers License No. ____________________ State: ____________
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B. BENEFICIARY
Please indicate full name and relationship to the Proposed Insured. (please print)
The right to change the beneficiary as to any proceeds is reserved to the owner.
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C. POLICY OWNER (IF OWNER IS NOT THE PROPOSED INSURED)
3 . Address _____________________________________________
1. Name of Owner*/Trust or Corporation STREET ADDRESS
_____________________________________________________________
______________________________________________________
_____________________________________________________________ STREET ADDRESS
______________________________________________________
CITY STATE ZIP
2. Soc. Sec. Number______-___-______ or
4. Relationship to Insured _______________________________
Tax ID Number___-______________
5. Date of Birth _________________________________________
*If Owner is a Trust, please complete Verification of Trust page
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D. CORRESPONDENCE INFORMATION
Name/Address/Phone for mailing of policy statements and Name/Address/Phone for mailing of Premium Notices: (If
correspondence other than premium notices: same as address to left, state "same")
______________________________________________________________ _________________________________________________________
NAME NAME
______________________________________________________________ _________________________________________________________
STREET ADDRESS STREET ADDRESS
______________________________________________________________ _________________________________________________________
CITY STATE ZIP CITY STATE ZIP
______________________________________________________________ _________________________________________________________
PHONE FAX PHONE FAX
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Page 1
[LOGO] Part A Statements to the Company's Agent
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E. BENEFITS F. PAYMENT DETAILS
1. Premium billing interval
1. Basic Sum Insured (BSI) $ _________________ [_] Annual [_] Semiannual
[_] Quarterly [_] Monthly-(automatic deduction)
2. Death Benefit Option (choose one) [_] Monthly - EC Case# ___________________________
[_] Option A - Sum Insured only
[_] Option B - Insured plus Account Value 2. Planned Premium (Check a or b, or Target Premium will be
billed)
3. Life Insurance Definition
[_] Cash Value Accumulation Test (must select Option A) a. [_] $ ______________annually for _____________ year(s).
[_] Guideline Premium Test Optional: Annual Increase of ___% OR
4. Additional benefits Additional first year Planned Premium $ _________________
[_] Additional Sum Insured (check no more than one, if desired)
[_] Level Sum Insured of $_______________ for life b. [_] Customized Schedule (list by policy year or years)
[_] Initial Sum Insured of $ ____________ increasing Policy Year(s) Planned Premium Amount
by [_] ___% or [_] $ ________________ -------------- ----------------------
per year for life of policy _____-_____ $_____________ (1)
[_] Customized Level or Increasing Schedule _____-_____ $_____________ (2)
(list by policy year or years, ASI amount may not decrease _____-_____ $_____________ (3)
Policy Year(s) ASI Amount _____-_____ $_____________ (4)
-------------- ---------- _____-_____ $_____________ (5)
______-_______ $________________ (1) _____-_____ $_____________ (6)
______-_______ $________________ (2) _____-_____ $_____________ (7)
______-_______ $________________ (3) _____-_____ $_____________ (8)
______-_______ $________________ (4) _____-_____ $_____________ (9)
______-_______ $________________ (5) ----------------------------------------------------------
______-_______ $________________ (6)
______-_______ $________________ (7) ----------------------------------------------------------
______-_______ $________________ (8) G. RIDERS
______-_______ $________________ (9)
______-_______ $________________ (10) [_] Living Care Benefit
[_] Enhanced Cash Value Rider
[_] Premium Cost Recovery for life of policy [_] Other(s)
[_] Optional Recovery Increase Percentage ____% ___________________________________________________
[_] Optional Recovery Increase years__________ ___________________________________________________
___________________________________________________
___________________________________________________
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H. TELEPHONE LOAN OPTION
I direct the Company to act upon telephone instructions from the owner (a trustee, if the owner is a trust, or an authorized
business official, if the Owner is a business entity) to process policy loans, subject to the provisions of the policy, and any
other requirements. [_] Yes [_] No
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Page 3 (Variable Investment Options) Must Be Completed
Page 2
John Hancock.
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THIS PAGE MUST BE COMPLETED FOR ALL VARIABLE PRODUCTS
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I. PLAN
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Choose One:
[_] MEVL 3 [_] Other (if applicable): ______________________
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J. VARIABLE INVESTMENT OPTIONS
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Percentages must be Whole and Total 100%
Equities (Mid Cap) International/Global Equities Bonds
___% Mid Cap Value ___% Global Equity ___% Short-Term Bond
___% Mid Cap Growth ___% International Balanced ___% Bond Index
___% Real Estate Equity ___% International Equity Index ___% Global Bond
___% Small/Mid Cap CORE ___% International Opportunities ___% Sovereign Bond
___% Small/Mid Cap Growth ___% Emerging Markets Equity ___% High Yield Bond
Equities (Large Cap) ___% International Equity Index Cash Equivalents/Fixed Account
___% Managed Equities (Small Cap) ___% Money Market
___% Growth & Income ___% Small Cap Value ___% Fixed Account*
___% Equity Index ___% Small Cap Growth
___% Large Cap Value Other(s) if available
___% Large Cap Growth ___% ________________ ___% ______________
___% ________________ ___% ______________
*Liquidity restrictions apply when allocating funds to the Fixed Account
_____
1 . Have you received a prospectus for
the policy applied for? (If YES, Prospectus Date: ________________ ) [_] Yes [_] No
2. Is the policy and allocation of subaccounts in accord
with your insurance objectives and your
anticipated financial needs? [_] Yes [_] No
3. Have you received an illustration of benefits
based on your Planned Premium? [_] Yes [_] No
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Page 3 (Variable Investment Options) NY
[LOGO] Part A Statements to the Company's Agent
L. UNDERWRITING INFORMATION
1. Has the Proposed Insured done in the past seven years, or intend to do any:
a. flying except as a passenger on regularly scheduled airlines? [_] Yes [_] No
(If yes, please complete aviation questionnaire.)
b. skin/scuba diving, parachuting, motorized racing, or other hazardous sports? [_] Yes [_] No
(If yes, please complete avocation questionnaire.)
2. In the past 10 years has the Proposed Insured been convicted of two or more motor [_] Yes [_] No
vehicle moving violations or had a driving license suspended or revoked?
3. In the past 10 years has the Proposed Insured been convicted of or incarcerated for the [_] Yes [_] No
violation of any criminal law (unless later acquited), are any criminal charges now pending
against any person, or is any person currently on probation?
4. Does the Proposed Insured intend to reside or travel outside the U.S. or Canada? [_] Yes [_] No
If any of questions 2 - 4 are answered "yes", please explain:__________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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M. OTHER INSURANCE/REPLACEMENT INFORMATION
1. Give information indicated as to all insurance in force on the Proposed Insured, including term riders.
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Company Issue Year Plan Amount ADB Amount Business Insurance?
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[_] Yes [_] No
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[_] Yes [_] No
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[_] Yes [_] No
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[_] Yes [_] No
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[_] Yes [_] No
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2. Is any other insurance application now pending or contemplated on the life of [_] Yes [_] No
the Proposed Insured?
If yes, what company(ies)/amounts?__________________________________________________________________________________________
3. Is the insurance applied for intended to replace or change any life insurance or annuity [_] Yes [_] No
now in force on the Proposed Insured? (If yes, give writing company of insurance being replaced,
policy number, and insurance amount.)
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Company Policy # Amount Company Policy # Amount
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3b. Check this box if this case is a 1035 exchange. [_]
4. Has any application for life, disability, or health insurance on the Proposed Insured [_] Yes [_] No
ever been declined, postponed, or modified? (If "Yes," give most recent company,
including John Hancock.)____________________________________________________________________________________________________
COMPANY APPROXIMATE DATE
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N. SPECIAL REQUESTS
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Page 4 NY
[LOGO]
Part B Statements to the Company's Agent
COMPLETE FOR NON-MEDICAL APPLICATIONS ONLY
Please give full details below for every "Yes" answer to Questions 1 - 4.
1. Has the Proposed Insured ever been treated for or had any known indication [_] Yes [_] No
of disease of the heart or blood vessels, chest pain or high blood pressure,
stroke or paralysis, diabetes, tumor or cancer, convulsions, kidney disease,
gastro-intestinal disease, mental or psychiatric disorder, lung or respiratory
disease, or blood disorder?
2. Has the Proposed Insured had or ever been diagnosed or treated by a [_] Yes [_] No
physician or other medical practitioner for ARC and/or Acquired Immune
Deficiency Syndrome (AIDS)?
3. Within the past 5 years has the Proposed Insured received counseling or treatment regarding [_] Yes [_] No
the use of alcohol, drugs, illegal drugs, or used any illegal drug or controlled substance?
4. Other than the above, within the past 5 years has the Proposed Insured
a) been admitted to a hospital or other medical or rehabilitation facility? [_] Yes [_] No
b) consulted or been treated by a physician, or had a physical exam or checkup? [_] Yes [_] No
5. Is the Proposed Insured currently taking any prescription drug? [_] Yes [_] No
If yes, what drugs? How frequently? __________________________________________________________________________________________
______________________________________________________________________________________________________________________________
6a. If the Proposed Insured has a personal physician, please enter name, address, and details below. Otherwise leave blank.
______________________________________________________________________________________________________________________________
FIRST NAME MI LAST NAME
______________________________________________________________________________________________________________________________
STREET ADDRESS CITY STATE ZIP
6b. Date last seen Reason(s) last seen
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Details to "yes" answers.
Question No. ______________________________________________ Question No. ______________________________________________
Condition _________________________________________________ Condition _________________________________________________
___________________________________________________________ ___________________________________________________________
Date of onset ______________ Last occurrence ____________ Date of onset ______________ Last occurrence ____________
Treatment/medication, if any ______________________________ Treatment/medication, if any ______________________________
Names/addresses of physicians/hospitals providing treatment Names/addresses of physicians/hospitals providing treatment
___________________________________________________________ ___________________________________________________________
___________________________________________________________ ___________________________________________________________
___________________________________________________________ ___________________________________________________________
___________________________________________________________ ___________________________________________________________
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Question No. ______________________________________________ Question No. ______________________________________________
Condition _________________________________________________ Condition _________________________________________________
___________________________________________________________ ___________________________________________________________
Date of onset ______________ Last occurrence ____________ Date of onset ______________ Last occurrence ____________
Treatment/medication, if any ______________________________ Treatment/medication, if any ______________________________
Names/addresses of physicians/hospitals providing treatment Names/addresses of physicians/hospitals providing treatment
___________________________________________________________ ___________________________________________________________
___________________________________________________________ ___________________________________________________________
___________________________________________________________ ___________________________________________________________
___________________________________________________________ ___________________________________________________________
Please record any additional details on a separate piece of paper.
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Page 5 NY
[Logo]
AUTHORIZATION AND ACKNOWLEDGEMENT
I hereby authorize any licensed physician, medical practitioner, hospital,
clinic, or other medical or medically related facility, insurance company, the
Medical Information Bureau or other organization, institution, or person that
has any records or knowledge regarding the undersigned to give to the Company or
its reinsurer(s) any such information, including information concerning every
condition for which each has been under observation or treatment, including if
the information specified contains information related to treatment for drug
and/or alcohol abuse or for psychiatric and/or mental conditions, the history
obtained, physical and laboratory findings, diagnosis and treatment. I hereby
authorize the Company to release any records or other information in its
possession regarding the undersigned to the JH Networking Insurance Agency, Inc.
which may use this information in its efforts to secure insurance coverage for
substandard risks with other insurance companies, a list of which is available
upon request.
I acknowledge receipt of the Federal Fair Credit Reporting Act and the New
York Fair Credit Reporting Act notice which contains a notice concerning the
Medical Information Bureau.
A copy of this authorization is as valid as the original. This
authorization is valid for 24 months from the date below.
__________________________________ _______________________ 20_________________
Signature of Proposed Insured Date
________________________________________________________________________________
AGREEMENTS
All statements in this application are, to the best of my knowledge and belief,
true, complete, and correctly recorded. I assent to this application and also
agree that:
1. The statements and answers in this application are representations and not
warranties and attachments hereto will be relied upon and form the basis of
any insurance.
2. No information will be considered as having been given to John Hancock
unless it is written in this application.
3. No agent, producer, or medical examiner or any other person, except an
officer of John Hancock, is authorized to make or discharge contracts or
waive or change any of the conditions or provisions of any application or
policy, or to accept risks or pass on insurability. Any such unauthorized
action is not notice to or knowledge of the company. A medical examiner is
not an agent of the Company. In order for any of the above events to take
effect they must be provided for in writing signed by an officer of the
Company.
4. Coverage will take effect as provided in and subject to the terms and
conditions of Conditional Temporary Insurance Agreement on pages 11 & 12
bearing the same date and number of this Part A if: (1) an advance payment
of at least the Minimum Temporary Insurance Premium is made with this Part A
which satisfies the requirements of such Conditional Temporary Insurance
Agreement; and (2) the amount applied for in this and all other applications
now pending with John Hancock Life Insurance Company does not exceed
$1,000,000 life insurance.
5. In cases other than those described in "4." above, any policy issued on the
basis of this application will take effect as of the Date of Issue, but (i)
only upon approval of the application by John Hancock and delivery to and
acceptance by the Applicant of the policy and payment of the minimum initial
premium (in accordance with the billing frequency chosen) and (ii) only if,
at the time of such delivery and payment, the person proposed for insurance
in Parts A and B of this application is living and has not consulted or been
examined or treated by a physician or practitioner since the latest Part B
was completed.
6. All benefits, payments, and values, including the Death Benefit and Account
or Cash Value, under any policy issued which is based upon the investment
experience of a separate investment account may increase or decrease in
accordance with the investment experience of the separate investment account
and are not guaranteed as to fixed dollar amount. The Account Value or Cash
Value may even decrease to zero.
7. The registered representative's signature below certifies that a prospectus
for the policy applied for has been given to the Proposed Insured and/or to
the Applicant and that no written sales materials other than those approved
by John Hancock Life Insurance Company have been used.
_______________________________________________________ Dated At____________________________________ on _____________ ,_____________
Applicant's Signature City or Town State Date
_______________________________________________________ Dated At ___________________________________ on ______________ , ___________
Signature of Proposed Insured, if other than Applicant City or Town State Date
_______________________________________________________ Dated At ___________________________________ on ______________ , ___________
Witness(Agent must witness where required by law) City or Town State Date
________________________________________________________________________________
Page 6 NY
[LOGO]
VERIFICATION OF TRUST (IF APPLICABLE)
1. Names of Proposed Insured (please print): 5. Names of Additional Trustees:
_____________________________________________________ ______________________________________________
FIRST NAME MIDDLE INITIAL LAST NAME FIRST NAME MIDDLE INITIAL LAST NAME
______________________________________________
FIRST NAME MIDDLE INITIAL LAST NAME
2. Name of Trust:
_____________________________________________________ ______________________________________________
FIRST NAME MIDDLE INITIAL LAST NAME
_____________________________________________________ ______________________________________________
FIRST NAME MIDDLE INITIAL LAST NAME
_____________________________________________________
3. Name of Trustee: 6. Date of Trust _____/_____/_____
_____________________________________________________ 7. Trust established in state of ________________________
FIRST NAME MIDDLE INITIAL LAST NAME
4. Address of Trustee: 8. Taxpayer ID # (when available) ________________________
_____________________________________________________
STREET ADDRESS 9. Application Date _____/_____/_____
_____________________________________________________
CITY STATE ZIP
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The undersigned Trustee(s) certify that the following statements are true:
The Trustee(s) has the authority, either by the terms of the trust or
applicable state law, to own and purchase life insurance on the life of the
Insureds. The Trustee(s) signing this document and the application are
sufficient in number to act on behalf of the trust.
The trust document containing the names of the Trustee(s) and the date of the
trust is in full force and effect and existed prior to the date of the
application for life insurance.
The trust empowers the Trustee(s) to exercise any and all rights associated
with owning life insurance policies and the Trustee(s) can exercise these
rights without the consent of the Insured. These rights include but are not
limited to: surrendering the policy, withdrawing policy values, borrowing
against the policy values, assigning the policy, transferring ownership, and
changing the beneficiary.
The undersigned Trustee(s) agrees that John Hancock Life Insurance shall not be
responsible for the application or disposition of the proceeds of the said
policy purchased by the Trustee(s), and the payment to the Trustee(s) of the
proceeds of the policy shall fully discharge John Hancock Life Insurance from
all liability under the said policy to the extent of such payment. By signing
this verification form, the Trustee(s) verify that all information contained
herein is true and complete. We agree jointly and severally to indemnify the
insurer and its agents, and hold them harmless from and against all liability
as a result of claims, demands, or judgments against them arising from
effecting any insurance transactions in reliance on this certification.
Dated At ______________________________________________ on _________________________, 20__________
CITY OR TOWN STATE DATE
_________________________________________________ _____________________________________
SIGNATURE OF WITNESS SIGNATURE OF TRUSTEE
_____________________________________
SIGNATURE OF TRUSTEE
_____________________________________
SIGNATURE OF TRUSTEE
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Page 7 NY
[LOGO]
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PLEASE COMPLETE ANY SECTION BELOW THAT PERTAINS TO THIS CASE
I. COMPLETE FOR MODIFIED ENDOWMENTS
1. Does the sales illustration show that the policy applied for is a Modified Endowment Contract (MEC)? [_] Yes [_] No
2. If yes, has the Policyowner signed the MEC Acknowledgment Form below? [_] Yes [_] No
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II. COMPLETE FOR BUSINESS INSURANCE
1. Authorized officer signing the application
Name__________________________________________________ Title___________________________________________________
2. Amount of business insurance already in force on Proposed Insured $______________________________________________________
3. Proposed Insured's total compensation from the business for each of the last two years.
Year:_________ Compensation $_______________________ Year ____________ Compensation $ ____________________
4. Total book value of business $ _______________________ 5. Total market value of business $ ____________________
6. Year founded or incorporated__________________________ 7. % of business owned by Proposed Insured______________ %
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III. COMPLETE FOR ADVANCED SALES CASES
1. Does this insurance satisfy one of the estate and business needs listed below? [_] Yes [_] No
If yes, check one need catagory and one sales concept, if applicable.
1 [_] Estate Conservation 5 [_] Non-Qualified Retirement Plan
a [_] Irrevocable Trust Owned g [_] Salary Continuation
b [_] Adult Children Owned h [_] True Deferral
2 [_] Business Continuation i [_] Dealth Benefit Only
c [_] Stock Redemption j [_] Severance Benefit
d [_] Stock Purchase 6 [_] Corporate Owned Insurance
3 [_] Qualified Retirement Plan (Pension, Profit Sharing, 401(k), HR-10) k [_] Endorsement Split Dollar
4 [_] Individually Owned Insurance l [_] Key Person
e [_] Collateral Assignment Split Dollar m [_] Business Loan
f [_] Executive Bonus 7 [_] Charitable Insurance
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AUTHORIZATION FOR AUTOMATIC DEDUCTION
I authorize the Company to deduct the monthly premiums for the policy applied for on this application from the bank account
listed below. I understand that the deduction will take place on or about the third Friday of each month.
Transit Routing Number _____________________________________ PC Control Number (If an existing account) ____________________
Bank Account Number ________________________________________ EFTS Transfer Code ____________________________________________
Name(s) of Depositor(s) ____________________________________ Signature(s) of Depositor(s) __________________________________
____________________________________ __________________________________
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Page 8
[LOGO]
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SALES CREDIT FOR APPLICATION
AGENCY NAME ORD. CODE CITY TAX GA/MA INITIALS
[__________________________]-[_][_][_]-[_][_][_][_]-[_][_][_]
SALES/STAFF MGR. NAME NUMBER 1 MARKETING REP. NAME CONTRACT MARKTG REP. # MARKTG TERR. # %
[__________________________]-[_][_][_][_][_][_]-[_______________________]-[_][_]-[_][_][_][_][_][_]-[_][_][_][_][_][_]-[_][_][_]
SALES/STAFF MGR. NAME NUMBER 2 MARKETING REP. NAME CONTRACT MARKTG REP. # MARKTG TERR. # %
[__________________________]-[_][_][_][_][_][_]-[_______________________]-[_][_]-[_][_][_][_][_][_]-[_][_][_][_][_][_]-[_][_][_]
SALES/STAFF MGR. NAME NUMBER 3 MARKETING REP. NAME CONTRACT MARKTG REP. # MARKTG TERR. # %
[__________________________]-[_][_][_][_][_][_]-[_______________________]-[_][_]-[_][_][_][_][_][_]-[_][_][_][_][_][_]-[_][_][_]
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SUPPLEMENTARY UNDERWRITING INFORMATION
1. Please provide the Proposed Insured's addresses for the last two years.
Time at Residence Street Address City/Town State ZIP
______yrs. _____mos. See Part A, Page 1
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______yrs. _____mos. ___________________________________________________________________________________________________
______yrs. _____mos. ___________________________________________________________________________________________________
2. Please provide the Proposed Insured's employment details for the last two years.
Time Employed Employer Name Street Address City/Town State ZIP
______yrs. _____mos. ___________________________________________________________________________________________________
______yrs. _____mos. ___________________________________________________________________________________________________
______yrs. _____mos. ___________________________________________________________________________________________________
3. Has Proposed Insured been known by any [_] Yes (what names)_________________________ [_] No
other names within the last ten years?
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---AGENT----------------------------------------------------
From my knowledge and investigation, the proposed insured is of
temperate habits and good moral character, and I know nothing Is the insurance applied for intended [_] Yes [_] No
affecting the insurability of the Proposed Insured not stated to replace or change any life insurance
hereon, and I recommend his/her acceptance without or annuity now in force on the Proposed Insured?
qualification. ------------------------------------------------------------
Proposed Insured interviewed by me on ___/___/___. This application and report have been reviewed by me,
and I recommend risk.
The Federal Fair Credit Reporting Act notice and the New York Fair
Credit Reporting Act Notice has been delivered as required. ________________________________________________________
Producer
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REQUEST FOR AUTOMATIC DEDUCTION BILLING: PLEASE SEND COPY TO AUTOMATIC COLLECTIONS
Please make sure that the Authorization for Automatic Deduction on Page 5 is completed and signed.
Name of Insured________________________________________________ Policy Number____________________________________________
1. All cases: please check one of a or b
[_] a. This is a new Automatic Deduction account. Please attach either 1) a blank voided check; 2) a copy of the Payor's
check for the initial premium; or 3) a copy of a cancelled check.
Note: Do not send voided check until policy is issued.
[_] b. This is an addition to an existing Automatic Deduction account, Control Number:_______________________________
2. Please place policy on Automatic Deduction effective ________________/___________________.
3. If you have other comments, please check here and use reverse side
Agency Name____________________________________________ Ord Code______________________________________________
Submitted by___________________________________________ Date__________________________________________________
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Page 9 NY
[LOGO]
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NOTICE OF POTENTIAL INCOME TAX IMPLICATIONS FOR MODIFIED ENDOWMENT CONTRACTS
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Certain amendments made to the Internal Revenue Code by the Technical and
Micellaneous Revenue Act of 1988 (TAMRA) have changed the income taxation of
cash withdrawn from certain affected life insurance policies called Modified
Endowment Contracts, or MECs. Due to the amount of premium you plan to pay into
this policy, you will be affected by this law.
It is important for you to understand that all distributions made from your
policy as applied for, including policy loans, withdrawals, partial surrenders
and certain dividends, will be considered to be a distribution of any gain. This
means that if your policy is in a gain position when the withdrawal is made
(i.e., the value of your policy exceeds the amount you've paid into it), you
will owe ordinary income tax on the amount you withdraw. In addition, a 10%
penalty tax is imposed by the IRS on any taxable distribution made prior to age
59 1/2, except on disability or if taken in the form of an annuity.
The insurance proceeds payable to your beneficiary upon the death of the
Proposed Insured will continue to be income tax free under current legislation.
This notice is designed to inform you of the income taxation of life insurance
based upon our understanding of the information currently available. It is not
intended to provide you with legal advice, which neither John Hancock nor its
Representatives can give. Therefore, if you have questions as to the
applicability of any provision of the law, you should seek the advice of your
own tax and legal counsel.
If you wish to modify your planned premium payments to avoid creating a Modified
Endowment Contract, your Marketing Representative will assist you. Otherwise,
please sign the Acknowledgment below.
Policyowner Acknowledgment and Signature
I have read the above Notice of Potential Income Tax Implications. I understand
that my premium payments will cause the proposed policy to become a Modified
Endowment. I also understand the potential income tax effects of a distribution
from a Modified Endowment.
Policyowner Signature(s) _________________________________ Date ______________
_________________________________
sign here only if your Contract
will be a Modified Endowment
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- --------------------------------------------------------------------------------
REQUEST FOR AUTOMATIC DEDUCTION PLAN (CONTINUED)
Special Automatic Deduction Requests:
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Page 10
[LOGO](R)
DETACH THIS SECTION AND GIVE TO CLIENT
JOHN HANCOCK LIFE INSURANCE COMPANY
Notice to Each Person Proposed for New or Changed Coverage
As required by the Federal Fair Credit Reporting Act, we wish to advise that
in connection with the insurance (or change in coverage) applied for, an
investigative consumer report may be requested by the Company with respect to
any person proposed for insurance or change in coverage. Such a report may
contain information as to character, general reputation, personal
characteristics and mode of living of such person, and is customarily obtained
through personal interviews with neighbors, friends, or associates of the
subject of the report. You have a right to make a written request for
information as to the nature and scope of any such report under the Act by
writing to us at:
John Hancock
Underwriting - Federal Fair Credit Control
P.O. Box 111 John Hancock Place
Boston, Massachusetts 02117
For identification purposes, your request must include your full name,
birthdate, address, and any applicable policy number.
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RECEIPT AND CONDITIONAL TEMPORARY INSURANCE AGREEMENT
. This Receipt and Conditional Temporary Insurance Agreement is governed by
Agreement 4 of the application bearing the same number as this receipt.
. There is a total temporary insurance coverage limit of $250,000 on all
applications pending on each person proposed for insurance with John Hancock
Life Insurance Company regardless of the number of applications, and the face
amounts of the policies applied for.
-----------------------------------------------------------------------------
Proposed Insured _____________________ Application Number ________________
Plan _________________________________ Date ______________________________
Received from _________________________________ the sum of $ ________________
paid with application to the Company with the same date and number as this
receipt. This receipt is issued on the condition that any check, draft, or
other order for the payment of money is good and can be collected.
Please make all premium checks payable to the company under which your
application is being made (John Hancock Life at John Hancock Place, Boston,
MA. Do not make check payable to the agent or leave the payee blank.
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Conditions of Temporary Insurance Coverage. 1)The amount received must be at
least the Minimum Temporary Insurance Premium, 2) Parts A and B of the
application and any required medical examinations and tests must be completed,
and 3) The following questions are answered "NO".
a. In the past two years, has any person proposed for insurance consulted
a physician, been diagnosed with, or had treatment for heart disease,
stroke, or cancer?_______
b. Has any person proposed for insurance been hospitalized within the past
6 months or been advised by a physician that he or she needs
hospitalization for any reason (other than for normal pregnancy)?______
c. Within the past 5 years has any person received counseling or treatment
regarding the use of alcohol, drugs, illegal drugs, or used any illegal
drug or controlled substance?_______
d. In the past 3 years has any person had a driving license suspended or
revoked?______
Commencement of Temporary Insurance Coverage. If the above Conditions of
Temporary Insurance Coverage are met, coverage in accordance with the terms and
conditions of the policy applied for will take effect on the latest "Completion
Date" of all persons proposed for insurance. Each person's "Completion Date"
will be the date of completion of the latest of the Parts A and B of the
application and any medical examinations and tests required by the Company's
published initial underwriting requirements, according to the age and amount
applied for.
Amount of Temporary Insurance Coverage. The amount of Coverage will be the
lesser of: 1) the amount applied for on each person excluding the amount payable
under Option 1 of the Paid Up Insurance Rider, if applied for, unless the amount
received with the application is equal to or greater than (i) the Minimum
Temporary Insurance Premium plus (ii) the Lump Sum Payment shown on Page 2
(Traditional/ Term) in Box 1; and 2) $250,000. However, the amount of coverage
will never exceed $250,000 less the total of all amounts payable under all
conditional temporary insurance agreements issued by John Hancock Life Insurance
Company in connection with any insurance application pending on the Proposed
Insured as of the date of this Receipt and Conditional Temporary Insurance
Agreement. No benefit will be paid under this Agreement if the Proposed
Insured's death results, directly or indirectly, or wholly or partially, from
intentionally self-inflicted injury while sane, or self-inflicted injury while
insane.
(continued on reverse)
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[LOGO]
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DETACH THIS SECTION AND GIVE TO CLIENT
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Information obtained about your insurability will be treated as confidential.
The Company may, however, make a brief report thereon to the Medical Information
Bureau, a non-profit membership organization of life insurance companies which
operates an information exchange on behalf of its members. If you apply to
another Bureau member company for life or health insurance coverage, or a claim
for benefits is submitted to such a company, the Bureau, upon request, will
supply such company with the information it may have in its file.
Upon receipt of a request from you, the Bureau will arrange disclosure of any
information it may have in your file. If you question the accuracy of
information in the Bureau's file, you may contact the Bureau and seek a
correction in accordance with procedures similar to those set forth in the
Federal Fair Credit Reporting Act.
The address of the Bureau's information office is: Medical Information Bureau
Post Office Box 105, Essex
Station Boston,
Massachusetts 02112
Telephone (617) 426-3660
The Company may also release limited information in its file to other properly
authorized life insurance companies to which you may apply for life or health
insurance, or to which a claim for benefits may be submitted.
Information may be released to proper regulatory agencies on request and to
insurance companies in connection with reinsurance.
Underwriting actions are not reported to the Bureau, nor is the Company informed
through the Bureau of the underwriting actions of other companies to whom you
may have applied for life or health insurance.
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Receipt and Conditional Temporary Insurance Agreement (continued)
Termination of Temporary Insurance Coverage. The conditional temporary
insurance coverage provided by this Agreement will end on the earliest of:
1) The commencement of coverage under the policy issued on the basis of the
application.
2) The date the Applicant refuses to accept the policy as offered for
delivery.
3) The date the application is declined or deemed declined. (Policy is
deemed declined if not approved within 60 days of the latest Completion
Date.) Notice of any such declination will be furnished.
If termination occurs under 2) or 3) above, the amount paid will be returned on
surrender of this Receipt. In no event will coverage be in effect under both
this Conditional Temporary Insurance Agreement and any policy issued on the
basis of the application, and any amendment thereto, with the same date and
number as this Receipt and Conditional Temporary Insurance Agreement.
Commencement of Coverage Under the Policy. Coverage under any policy issued on
the basis of the application will replace the coverage provided by this
Agreement as of the policy Date of Issue but only if:
1) The policy is delivered to and accepted by the Applicant while all
persons proposed for insurance are living and within 60 days of the
latest "Completion Date," and
2) The balance of any premium required for the policy as delivered is paid
while all persons proposed for insurance are living and within 60 days
after the latest "Completion Date".
Minimum Temporary Insurance Premium. The Minimum Temporary Insurance Premium is
one month's proportionate part of the premium according to the Company's
published rates for the policy and premium interval applied for.
John Hancock Life Insurance Company
___________________________________ _____________________________________
PROPOSED INSURED DATE MARKETING REPRESENTITIVE DATE
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(To be used in event of refund of payment)
Received of the John Hancock Life Insurance Company Boston, Massachusetts,
the sum of $______________________________. The amount mentioned in the
receipt on the reverse side hereof.
Date__________________________, __________
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Page 12 NY