[LOGO]
This application for life Insurance is to
John Hancock Life Insurance Company ("the Company),
200 Clarendon Street, John Hancock Place, Boston, Massachusetts 02117.
This application is part of the case applied for in
Master Application Number __________ (if applicable)
M Proprietary Products
---------------------------------------------------
[LOGO]
Part A Statements to the Company's Agent
A. PROPOSED PARTICIPANT
1. Name of Proposed Participant (please print): 10. Address __________________________________
First _____________________________ MI ______ STREET ADDRESS
Last ________________________________________ _________________________________________
CITY STATE ZIP
2. Sex [_] Male [_] Female 11. Home Phone ( ___ ) _________--____________
3. Date of Birth ____/____/____ 12. Work Phone ( ___ ) _________--____________
4. Place of Birth _________________________________ Fax Number ( ___ ) _________--______________
STATE COUNTRY, IF NOT USA
5. Soc. Sec. Number _____ - _____ - ______ 13. Best time and place for Underwriting to call
(in Proposed Participant's local time
6. Height ____ft. ____in. 7. Weight ____________ zone)_____________________________________
8. Occupation ___________________________________ 14. Has the Proposed Participant smoked or used
the past 12 months? any other tobacco product, i.e. cigars, pipes,
snuff, chewing tobacco, etc., in the past 12
months?
9. Driver's License State ____ Number _______________ [_] Yes [_] No
- ------------------------------------------------------------------------------------------------------------------------------------
State of Issue: New York
Page 1
Part A Statements to the Company's Agent
B. CERTIFICATEHOLDER
1. Certificateholder Complete questions 3-5 if Certificateholder is a Trust
[_] Trust 3. Name of Trust
___________________________________
[_] Corporation ________________________________________________________
(only available if applying for Variable MasterPlan Plus) ________________________________________________________
___
[_] Other (Complete question 6.) 4. Trustee(s)
______________________________________________
2. Tax ID or Soc. Sec. Number _______________________
5. Date of Trust ______/_________/______
COMPLETE VERIFICATION OF TRUST FORM ON PAGE 8 IF CERTIFICATE IS TO BE OWNED BY A TRUST
- ------------------------------------------------------------------------------------------------------------------------------------
6. Other Certificateholders, if any
Name of Relationship Social Security Date of Birth
Certificateholders to Proposed Participant Number
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
- ------------------------------------------------------------------------------------------------------------------------------------
7. Name/Address/Phone for mailing certificate statements 8. Name/Address/Phone for mailing of Premium notices:
and correspondence other than premium notices: (If same as address to left, state "same".)
_______________________________________________ ______________________________________________
Name Name
_______________________________________________ ______________________________________________
Street Address Street Address
_______________________________________________ ______________________________________________
City State Zip City State Zip
_______________________________________________ ______________________________________________
Phone Fax Phone Fax
- ------------------------------------------------------------------------------------------------------------------------------------
C. UNDERWRITING INFORMATION
1. In the past 7 years, has the Proposed Participant done, or does the Proposed
Participant intend to do any:
a. Flying except as a passenger on regularly scheduled airlines?
(if yes, please complete aviation questionnaire.) [_] Yes [_] No
b. skin/scuba diving, parachuting, motorized racing, or other hazardous
sports?
(if yes, please complete avocation questionnaire.) [_] Yes [_] No
2. In the past 7 years, has the Proposed Participant been convicted of two or
more Motor vehicle moving violations or had a driving license suspended or
revoked? [_] Yes [_] No
3. In the past 7 years, has the Proposed Participant been convicted of the
Violation of any criminal law, or are there any criminal charges now
pending against the Proposed Participant? [_] Yes [_] No
4. Does the Proposed Participant intend to reside or travel outside the
U.S. or Canada? [_] Yes [_] No
If any of questions 2-4 are answered "yes", please explain:
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
- ------------------------------------------------------------------------------------------------------------------------------------
Page 2
Part A Statements to the Company's Agent
D. OTHER INSURANCE/REPLACEMENT INFORMATION
- ------------------------------------------------------------------------------------------------------------------------------------
1. Give information indicated for all insurance in force on the Proposed Participant, including term riders.
- ------------------------------------------------------------------------------------------------------------------------------------
Company Issue Year Plan Amount ADB Amount Business Insurance
- ------------------------------------------------------------------------------------------------------------------------------------
[_] Yes [_] No
- ------------------------------------------------------------------------------------------------------------------------------------
[_] Yes [_] No
- ------------------------------------------------------------------------------------------------------------------------------------
[_] Yes [_] No
- ------------------------------------------------------------------------------------------------------------------------------------
[_] Yes [_] No
- ------------------------------------------------------------------------------------------------------------------------------------
[_] Yes [_] No
- ------------------------------------------------------------------------------------------------------------------------------------
2. Is any other insurance application now pending or contemplated on the life of [_] Yes [_] No
the Proposed Participant? (Include any Life, Disability, or Long Term Care)
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 Participant? (If yes, give writing of company of insurance
being replaced, policy/ certificate number, and insurance amount.)
- ------------------------------------------------------------------------------------------------------------------------------------
Company Policy/ Certificate # Amount
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
4. Has any application for life, disability, or health insurance on the Proposed Participant
ever been modified? (If "Yes", give most recent company, including John Hancock.) [_] Yes [_] No
- ---------------------------------------------------------------------------------------------
Company Approximate Date
- ------------------------------------------------------------------------------------------------------------------------------------
E. SPECIAL REQUESTS
- --------------------------------------------------------------------------------
F. BENEFICIARY
Please indicate the full name and relationship to the Proposed Participant.
(Please print.)
The right to change the beneficiary as to any proceeds is reserved
to the Certificateholder(s).
- --------------------------------------------------------------------------------
Page 3
PLEASE COMPLETE THIS PAGE IF MAJESTIC VARIABLE UNIVERSAL LIFE 98 IS DESIRED
G. BENEFITS H. PREMIUM
1. Sum Insured (SI) $___________________ 1. Premium Billing Interval
[_] Annual [_] Quarterly
[_] Semiannual [_] Monthly- (premiumatic)
- ------------------------------------------------------------------------------------------------------------------------------------
5. Death Benefit Option (choose one) 6. Initial Premium ____________________
[_] Option A- Sum Insured Only ---------------------------------------------------------
[_] Option B- Sum Insured plus Account Value 7. Planned Premium (Check a or b, or Target Premium will
[_] Option M- Sum Insured plus Option Extra Death be billed.)
Benefit with calculation beginning at certificate year ___ a. [_] $__________ annually for _______ year(s)
- ---------------------------------------------------------------------- Optional: Annual Increase of _____% OR
9. Life Insurance Definition (choose one) [_] $__________ annually for _______ year(s)
[_] Cash Value Accumulation Test Additional first year Planned Premium $__________
[_] Guideline Premium Test (Option M not allowed)
- ---------------------------------------------------------------------- 8. [_] Customized Schedule (list by certificate year or
10. Additional Benefits years):
[_] Enhanced Cash Value Rider Certificate Year(s) Planned Premium Amount
- ---------------------------------------------------------------------- _____ - ______ $_________________(1)
I. VARIABLE PRODUCTS INFORMATION _____ - ______ $_________________(2)
_____ - ______ $_________________(3)
_____ - ______ $_________________(4)
COMPLETE SECTIONS J, K & L ON PAGE 4A _____ - ______ $_________________(5)
OF THIS APPLICATION _____ - ______ $_________________(6)
_____ - ______ $_________________(7)
_____ - ______ $_________________(8)
_____ - ______ $_________________(9)
_____ - ______ $_________________(10)
(If more space is needed, attach separate schedule)
- ------------------------------------------------------------------------------------------------------------------------------------
The certificate applied for on this application is variable universal life
insurance.
In order to qualify as life insurance under section 7702 of the Internal Revenue
Code, this certificate has a Minimum Death Benefit.
It is based on one of two allowable death benefit compliance tests provided in
section 7702.
Under the Cash Value Accumulation Test (CVAT), the Minimum Death Benefit is
equal to a percentage of the account value of the certificate. The percentages
depend on the sex, risk class and attained age of each Participant.
Under the Guideline Premium Test (GPT), the Minimum Death Benefit is also equal
to a percentage of the account value of the certificate. Under the GPT, the
percentages vary only be the attained age of the Participant. Under this test,
the premiums paid under the certificate also cannot exceed the greater of the
guideline single premium or the sum of the guideline level premiums to date.
These guideline premiums will be provided. This premium requirement serves to
limit the amount of the total investment in the certificate relative to the
death benefit.
The percentages used to determine the Minimum Death Benefit are shown in the
certificate.
The test is chosen at the time of application and cannot be changed after the
certificate is issued.
The appropriate choice for you will depend on your financial needs. Generally,
the CVAT may be a better choice if you expect to pay most of your premiums in
the earlier years. The GPT may be the better choice if you expect to pay
premiums on a level basis over a long period. You should consult your agent [and
review illustrations using each test] before you make your selection.
I have read this Disclosure statement and I understand it.
- ------------------------------------- --------------------------------------
Signature of Proposed Signature of Joint
Certificateholder Certificateholder (if applicable)
- ------------------------------------- --------------------------------------
Signature of Agent Date
Page 4 (Majestic VUL98)
Part A Statements to the Company's Agent
PLEASE COMPLETE THIS PAGE IF VARIABLE MASTERPLAN PLUS IS DESIRED
G. BENEFITS H. PREMIUM
1. Sum Insured (SI) $___________________ 1. Premium Billing Interval
[_] Annual [_] Quarterly
[_] Semiannual [_] Monthly- (premiumatic)
- ------------------------------------------------------------------------------------------------------------------------------------
2. Death Benefit Option (choose one) 2. Initial Premium ____________________
[_] Option A- Sum Insured Only
[_] Option B- Sum Insured plus Account Value
[_] Option M- Sum Insured plus Option Extra Death 3. Planned Premium (Check a or b, or Target Premium will be
Benefit with calculation beginning at certificate year billed.)
b. [_] $__________ annually for _______ year(s)
- --------------------------------------------------------------------- Optional: Annual Increase of _____% OR
3. Life Insurance Definition (choose one) [_] $__________ annually for _______ year(s)
[_] Cash Value Accumulation Test Additional first year Planned Premium $__________
[_] Guideline Premium Test (Option M not allowed)
- --------------------------------------------------------------------- b. [_] Customized Schedule (list by certificate year or
4. Additional Benefits years):
[_] Enhanced Cash Value Rider Certificate Year(s) Planned Premium Amount
- --------------------------------------------------------------------- _____ - ______ $_________________(1)
I. VARIABLE PRODUCTS INFORMATION _____ - ______ $_________________(2)
- --------------------------------------------------------------------- _____ - ______ $_________________(3)
_____ - ______ $_________________(4)
_____ - ______ $_________________(5)
COMPLETE SECTIONS J, K & L ON PAGE 4A _____ - ______ $_________________(6)
OF THIS APPLICATION _____ - ______ $_________________(7)
_____ - ______ $_________________(8)
_____ - ______ $_________________(9)
_____ - ______ $_________________(10)
(If more space is needed, attach separate schedule)
- ------------------------------------------------------------------------------------------------------------------------------------
The certificate applied for on this application is variable universal life
insurance.
In order to qualify as life insurance under section 7702 of the Internal Revenue
Code, this certificate has a Minimum Death Benefit.
It is based on one of two allowable death benefit compliance tests provided in
section 7702.
Under the Cash Value Accumulation Test (CVAT), the Minimum Death Benefit is
equal to a percentage of the account value of the certificate. The percentages
depend on the sex, risk class and attained age of each Participant.
Under the Guideline Premium Test (GPT), the Minimum Death Benefit is also equal
to a percentage of the account value of the certificate. Under the GPT, the
percentages vary only be the attained age of the Participant. Under this test,
the premiums paid under the certificate also cannot exceed the greater of the
guideline single premium or the sum of the guideline level premiums to date.
These guideline premiums will be provided. This premium requirement serves to
limit the amount of the total investment in the certificate relative to the
death benefit.
The percentages used to determine the Minimum Death Benefit are shown in the
certificate.
The test is chosen at the time of application and cannot be changed after the
certificate is issued.
The appropriate choice for you will depend on your financial needs. Generally,
the CVAT may be a better choice if you expect to pay most of your premiums in
the earlier years. The GPT may be the better choice if you expect to pay
premiums on a level basis over a long period. You should consult your agent
[and review illustrations using each test] before you make your selection.
I have read this Disclosure statement and I understand it.
___________________________________________ ____________________________________________________
Signature of Proposed Certificateholder Signature of Joint Certificateholder (if applicable)
___________________________________________ ___________________________________________________
Signature of Agent Date
Page 4 (Variable MasterPlan Plus)
J. PLAN
Choose One:
[_] Majestic VUL 98 [_] Variable MasterPlan Plus
- -------------------------------------------------------------------------------
K. SUBACCOUNT INVESTMENT OPTIONS
Percentages must be Whole and Total 100%
[Equities (Mid Cap) International/Global Equities Cash Equivalents/Fixed Account
______% Fundamental Mid Cap Growth ___% Emerging Markets Equity ___% Money Market
______% Mid Cap Value II ___% Global Balanced ___% Fixed Account*
______% Mid Cap Growth ___% International Equity Index
______% Real Estate Equity ___% International Opportunities Outside Trust Funds
______% Small/Mid Cap CORE __% AIM V.I. Value
______% Small/Mid Cap Growth Bonds __% Fidelity VIP Contrafund
___% Active Bond __% Fidelity VIP Growth
Equities (Large Cap) ___% Bond Index __% Janus Aspen Global Technology
__% Large Cap Value Core II ___% Active Bond II __% Janus Aspen Worldwide Growth
___% Equity Index ___% Global Bond __% MFS New Discovery
___% Growth & Income ___% High Yield Bond __% Templeton International Securities
___% Short Term Bond
___% Managed
___% Large Cap Aggressive Growth Other (if available)
___% Large Cap Growth M Proprietary __% __________________
___% Large Cap Value __% Brandes International Equity Fund __% __________________
__% Enhanced U.S. Equity Fund __% __________________
__% Frontier Capital Appreciation __% __________________
Equities (Small Cap) __% Turner Core Growth __% __________________
___% Small Cap Growth
___% Small Cap Value]
*Liquidity restrictions apply when allocating funds to the Fixed Account
- ----------------------------------------------------------------------------------------------------------------------------------
L. SUITABILITY
- --------------------------------------------------------------------------------
1. Have you received a prospectus for
the certificate applied for? (If YES, Prospectus Date:____________) [_] Yes [_] No
2. Do you understand that the amount of Death Benefit and the
entire amount of the account value may increase or decrease
depending on investment experience? [_] Yes [_] No
3. Is the certificate and allocation of subaccounts in accord with the
applicable insurance objectives and anticipated financial needs? [_] Yes [_] No
- ------------------------------------------------------------------------------------------
Page 4A (Subaccount Investment Options
COMPLETE FOR NON-MEDICAL APPLICATIONS ONLY
Please give full details below for every "Yes" answer to Questions 1-4 as to the
person proposed for insurance. Be sure to include the names/addresses of any
treatment providers.
1. Within the past 7 years, has the Proposed Participant ever been treated for
or had any known indication 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? [_] Yes [_] No
2. Within the past 7 years, has the Proposed Participant had or been diagnosed
or treated by a physician or other medical practitioner for Human
Immunodeficiency Virus or Acquired Immune Deficiency Syndrome (AIDS)? [_] Yes [_] No
3. Within the past 7 years, has the Proposed Participant received counseling or
treatment regarding the use of alcohol, drugs, or used any illegal drug or
controlled substance? [_] Yes [_] No
4. Other than the above, within the past 7 years, has the Proposed Participant
a) Been admitted to a hospital or other medical or rehabilitation facility
(excluding admittance for HIV testing)? [_] Yes [_] No
b) consulted or been treated by a physician, or had a physical exam or
checkup (excluding admittance for HIV testing)? [_] Yes [_] No
5. Is the Proposed Participant taking any prescription drug? [_] Yes [_] No
What drugs? How frequently?
_____________________________________________________________________
6. If the Proposed Participant has a personal physician, please enter name,
address, and details below. Otherwise leave blank.
____________________________________________________________________________
First Name MI Last Name
____________________________________________________________________________
Street Address City State Zip Code
Date/Reason(s) last seen ___________________________________________________
- ------------------------------------------------------------------------------------------------------------------------------------
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
___________________________________________________________ ___________________________________________________________________
___________________________________________________________ ___________________________________________________________________
___________________________________________________________ ___________________________________________________________________
- ----------------------------------------------------------------------------------------------------------------------------------
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.
- ----------------------------------------------------------------------------------------------------------------------------------
Page 5
Statements to the Company's Agent
AGREEMENTS AND SIGNATURES
A. The statements and answers on pages 1 through 4 of Part A and Part B of the
attached application are, to the best of my knowledge and belief, complete,
true, and correctly recorded. All statements and answers are
representations and not warranties, and with all Parts B of the attached
application will form the basis for and be a part of any new certificate or
additional benefit provision issued on this application.
B. Coverage will take effect as provided in and subject to the terms and
conditions of Conditional Temporary Insurance Agreement pages 11 and 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 requirement of such Conditional Temporary Insurance
Agreement; and (2) the amount applied for in this and all other
applications now pending in John Hancock Life Insurance Company does not
exceed $1,000,000 life insurance.
C. If the applicant has a right to have the new certificate issued as
requested without completing any Part B, the new certificate will take
effect as of its Date of Issue, provided the initial payment has been made
with this application.
D. In cases other than those described in B and C above, any new certificate
or Benefit provision will take effect as of the Date of Issue of the
certificate, but: (1) only on delivery to and receipt by the Applicant of
the certificate and payment of the minimum initial premium thereupon and
(2) only if at the time of such delivery and payment each Proposed
Participant 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 pertaining to such person was completed.
E. No agent or medical examiner is authorized to make or discharge contracts
or waive or change any of the conditions or provisions of any application,
certificate, or receipt, 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.
F. All benefits, payments, and values , including the Death Benefit and
Account, under any certificate 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
may even decrease to zero.
G. The registered representative's signature below certifies that a prospectus
for the certificate applied for has been given to the Proposed Participant
and/or to the Applicant and that no written sales materials other than
those approved by John Hancock Life Insurance Company have been used.
Provisions H, I, J, K and L apply if the certificate applied for is the
result of a term conversion.
H. The new certificate will be a new, separate contract. If the new
certificate is issued in exchange for the original insurance, all liability
of the Company under the original insurance will cease when the new
certificate takes effect. Until the new certificate is issued, coverage
will still be in force under the original policy/ certificate. Coverage
under the new certificate will take effect as indicated in Paragraph C
above.
I. The application for the original insurance, unless such insurance is now
incontestable, and the application for each additional benefit provision
which is to be retained as specified on page 4 of this Application, unless
such provision is now incontestable, will also form a basis for and be a
part of the new certificate.
J. If the original policy/ certificate or benefit provision is being exchanged
and is subject to an assignment, the new certificate will be subject to the
same assignment unless it is discharged or, in the case of a
policy/certificate loan assignment, unless the indebtedness has been
repaid.
K. If the new certificate is issued in exchange for the original policy/
certificate, any nonforfeiture option election applicable to the original
policy/ certificate will be applicable to the new certificate, if
available, unless otherwise requested in writing.
L. Ownership and control of any certificate issued on the attached application
will be determined by the terms of the new certificate.
All statements and answers in this application are to the best of my knowledge
and belief, true and complete. They are representations and not warranties. I
understand that my employer is applying for life insurance on my life, and as a
consequence my employer has ownership rights. However, I have the right to
discontinue such insurance on my life at any time. I assent to this application.
Illustrations of benefits, including death benefits, certificate values and
surrender values are available upon request.
____________________________ Dated At ____________________________ on _________________, ______
Applicant's Signature City or Town State Date
_______________________________________________________________ _________________________________________________
Signature of Proposed Participant, if other than Applicant Witness (Agent must witness where required by law)
- ----------------------------------------------------------------------------------------------------------------------
Page 6
NOTICE OF INCOME TAX IMPLICATIONS FOR A MODIFIED ENDOWMENT
On November 10, 1988, the Technical and Miscellaneous Revenue Act of 1988
(TAMRA) was signed by President Reagan. This law changes 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 certificate, you will be affected by this law.
It is important for you to understand that all distributions made from your
certificate as applied for, including certificate loans, withdrawals, partial
surrenders and certain dividends (if applicable), will be considered to be a
distribution of any gain. This means that if your certificate is in a gain
position when the withdrawal is made (i.e., the value of your certificate
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 Participant(s) 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 on 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 acknowledgement below.
- --------------------------------------------------------------------------------
Certificateholder Acknowledgement and Signature
- --------------------------------------------------------------------------------
I have read the above notice of Potential Income Tax Implications. I understand
that my premium payments will cause the proposed certificate to become a
Modified Endowment. I also understand the potential income tax effects of a
distribution from a Modified Endowment.
Certificateholder Signature_____________________ Date_____________________
- --------------------------------------------------------------------------------
TAXPAYER IDENTIFICATION NUMBER
Enter the Certificateholder's taxpayer Social Security Number
identification number in the appropriate _____________________
box. For most individual taxpayers,
this is the social security number. If
applying for Variable MasterPlan Plus, this
is the Corporation's Tax ID Number
----------------------------
OR
----------------------------
Employer or Trust Taxpayer
ID number
______________________
----------------------------
I submit that the information provided about is true, correct, and
complete.
Signature ______________________________________ Date_____________________
- --------------------------------------------------------------------------------
Page 7
VERIFICATION OF TRUST
1. Names of Proposed Participant (please print): 5. Names of Additional Trustees:
_______________________________________________ ____________________________________________
First Name MI Last Name First Name MI Last Name
____________________________________________
2. Name of Trust: First Name MI Last Name
_______________________________________________
_______________________________________________ ____________________________________________
_______________________________________________ First Name MI Last Name
3. Name of Trustee: 6. Date of Trust __________/__________/_______
_______________________________________________
First Name MI Last Name
4. Address of Trustee: 7. Trust established in state of
_______________________________________________
Street Address __________________________________________________
_______________________________________________
City State Zip
8. Taxpayer ID # (when available)
__________________________________________________
9. Application Date
__________/__________/___________
- ------------------------------------------------------------------------------------------------------------------------------------
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 Participant.
The Trustee(s) signing this document and the application is/are sufficient in
number to act on behalf of the trust.
The trust document containing the name(s) 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 certificates and the Trustee(s) can exercise these rights
without the consent of the Participant. These rights include but are not limited
to: surrendering the certificate, withdrawing certificate values, borrowing
against the certificate values, assigning the certificate, transferring
ownership, and changing the beneficiary.
The undersigned Trustee(s) agree(s) that John Hancock Life Insurance Company
shall not be responsible for the application or disposition of the proceeds of
said certificate purchased by the Trustee(s), and the payment to the Trustee(s)
of the proceeds of the certificate shall fully discharge John Hancock Life
Insurance Company from all liability under said certificate to the extent of
such payment. By signing this verification form, the Trustee(s) verifies that
all information contained herein is true and complete. We agree jointly and
severally to indemnify the Company and its agents, and hold them harmless from
and against all liability as a result of claims, demands, or judgements 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
- --------------------------------------------------------------------------------
Page 8
SUPPLEMENTARY UNDERWRITING INFORMATION REQUIRED IN ALL MAJESTIC VUL98 CASES
1. Please provide the Proposed Participant addresses for the last two years.
Time at Residence Street Address City/Town State ZIP
______yrs. _____mos. See Part A, Page 1, Section A
--------------------------------------------------------------------------------------------
______yrs. _____mos. --------------------------------------------------------------------------------------------
2. Please provide the Proposed Participant's employment details for the last
two years.
Time Employed Employer Name Street Address City/Town State ZIP
______yrs. _____mos. ____________________________________________________________________________________________
______yrs. _____mos. ____________________________________________________________________________________________
3. How long have you known the Proposed Participant? ______________________
4. Are you related to the Proposed Participant? [_] Yes (relationship) _______________________________ [_] No
5. Has the Proposed Participant been known by any other names within the last 10 years?
[_] Yes (what names) _________________________________ [_] No
6. Approximate annual income of Proposed Participant $____________________
7. Approximate net worth of Proposed Participant $____________________
- ------------------------------------------------------------------------------------------------------------------------------------
I know nothing affecting the insurability of the Proposed ______AGENT_________________________________
Participant not stated hereon, and from my knowledge and
investigation I recommend his/her acceptance without Is the insurance applied for intended to replace or
qualification. change any life insurance or annuity now in force on the
Proposed Participant? [_] Yes [_] No
Proposed Participant interviewed by me on _______/_______/_______.
This application and report have been reviewed by me, and
The Federal Fair Credit Reporting Act notice has been delivered as I recommend the risk.
required.
_________________________________________________________
Producer
- ------------------------------------------------------------------------------------------------------------------------------------
AUTHORIZATION FOR PREMIUMATIC BILLING
I authorize John Hancock Company to deduct the monthly premiums for the
certificate 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)_______________________________
- -----------------------------------------------------------------------------------------------------------------------------------
SALE INFORMATION
Producer(s) Earning Credit for Case
Producer Name/Number Firm Name/Number % Credit
______________________________________ _____________________________ _______
______________________________________ _____________________________ _______
______________________________________ _____________________________ _______
______________________________________ _____________________________ _______
- ----------------------------------------------------------------------------------------------------------------------------------
Page 9
PLEASE COMPLETE ANY SECTION BELOW THAT PERTAINS TO THIS CASE
I. COMPLETE FOR 1035 EXCHANGE CASES
1. [_] Check this box if this case is a 1035 Exchange.
II. COMPLETE ONLY IF ADVANCE PAYMENT IS BEING MADE
1. How much advance payment is included with this Part A? $_________________
Write check to John Hancock Life Insurance Company. Accept advance payment
only if able to issue Receipt and Conditional TIA. (1035 external
replacements, individual certificates with face amounts over $1,000,000 may
not be prepaid.)
- -------------------------------------------------------------------------------
III. COMPLETE IF THIS IS A CONVERSION OF TERM INSURANCE
1. [_] This is a [_] Full [_] Partial Term Conversion from:
------------------------------------------------------------------------------------------------------------------------------
a. Certificate Number/Participant Conversion Type Amount Converted Amount Remaining In Force
------------------------------------------------------------------------------------------------------------------------------
Name Base Certificate Amount
-------------------------------------------------------------------------------------
------------------------------------ ___________Rider
-------------------------------------------------------------------------------------
___________Rider
------------------------------------------------------------------------------------------------------------------------------
b. Certificate Number/Participant Conversion Type Amount Converted Conversion Type
------------------------------------------------------------------------------------------------------------------------------
Name Base Certificate Amount
-------------------------------------------------------------------------------------
___________Rider
---------------------------------- -------------------------------------------------------------------------------------
# ___________Rider
--------------------------------------------------------------------------------------------------------------------------------
2. Is Participant now totally disabled, or is Participant receiving any payments for sickness or injury? [_] Yes [_] No
- ------------------------------------------------------------------------------------------------------------------------------------
IV. COMPLETE FOR MODIFIED ENDOWMENTS
1. Has the Certificateholder signed the MEC acknowledgement form? [_] Yes [_] No
- ----------------------------------------------------------------------------------------------------------------------------------
V. COMPLETE FOR BUSINESS INSURANCE
- ----------------------------------------------------------------------------------------------------------------------------------
1. Authorized Corporate Officer signing the application
Name __________________________________________________ Title_____________________________
2. Amount of business insurance already in force on Proposed Participant
$________________________________________________
3. Proposed Participant'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 Participant ___________%
- ------------------------------------------------------------------------------------------------------------------------------------
TO BE COMPLETED IN EVERY CASE
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 each of 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 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 acknowledge receipt of the Federal 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 of the Proposed Participant signature.
_______________________________________________ ________________________
Signature of Proposed Participant Date
- --------------------------------------------------------------------------------
Page 10
RECEIPT AND CONDITIONAL TEMPORARY INSURANCE AGREEMENT
John Hancock Life Insurance Company
PLEASE READ CAREFULLY
. This Receipt and Conditional Temporary Insurance Agreement is governed by
Agreement B 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 certificates applied for.
- --------------------------------------------------------------------------------
Proposed Participant______________________________________________________
Application Number________________________________________________________
Plan (choose one) [_] Majestic VUL [_] Variable MasterPlan Plus
Sum Insured at Issue $___________________________________________________
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 John Hancock Life Insurance
Company, 200 Clarendon Street, John Hancock Place, Boston, MA.
Do not make check payable to the agent or leave the payee blank.
- --------------------------------------------------------------------------------
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. Within the past 7 years, has the Proposed Participant consulted a physician
for, been diagnosed with, or had treatment for heart disease, stroke, or
cancer? [_] Yes [_] No
b. Has the Proposed Participant been hospitalized within the last 6 months or
been advised by a physician that he or she needs hospitalization for any
reason (other than for normal pregnancy)? [_] Yes [_] No
c. Within the past 7 years, has the Proposed Participant received counseling
or treatment regarding the use of alcohol, drugs, illegal drugs, or used
any illegal drug or controlled substance? [_] Yes [_] No
d. Within the past 7 years, has the Proposed Participant had a driving license
suspended or revoked? [_] Yes [_] No
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 certificate applied for will take effect on the latest
"Completion Date" of the Proposed Participant. The Proposed Participant's
"Completion Date" will be the date of completion of the latest of 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 in the application; 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 Participant as of the date of this Receipt and
Conditional Temporary Insurance Agreement. No benefit will be paid under this
agreement if the Proposed Participant'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)
- --------------------------------------------------------------------------------
Page 11
- --------------------------------------------------------------------------------
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 certificate issued on the basis of
the application.
2) The date the Applicant refuses to accept the certificate as offered for
delivery.
3) The date of the application is declined or deemed declined. (Certificate
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 in effect under both this
Conditional Temporary Insurance Agreement and any certificate 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 Certificate. Coverage under any certificate
issued on the basis of the application will replace the coverage provided by
this Agreement as of the certificate Date of Issue but only if:
1) The certificate is delivered to and accepted by the Applicant while the
Proposed Participant is living and within 60 days of
the latest "Completion Date" and
2) The balance of any premium required for the certificate as delivered is
paid while the Proposed Participant is living and within 60 days of 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 certificate and premium interval applied for.
Agreement and Signatures. All statements and answers on this Receipt and
Conditional Temporary Insurance Agreement are, to the best of my knowledge and
belief, true and complete. They are representations and not warranties. I assent
to the terms and conditions of this Receipt and Conditional Temporary Insurance
Agreement.
------------------------------
Not valid unless advance
___________________________________________ payment has been made, the
Proposed Participant Date application is complete,
and the questions on the
front are all answered "No."
Confirm the coverage
provided by this Agreement
with your agent.
------------------------------
___________________________________________
Producer Date
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
(To be used in the event of refund or repayment)
Received from the Company, Boston, Massachusetts, the sum of $__________________
The amount mentioned in the receipt on the reverse side hereof.
Date _____________________________, 20___
- --------------------------------------------------------------------------------
Page 12
REQUEST FOR PREMIUMATIC BILLING: PLEASE SEND COPY TO M SERVICE
Please make sure that the Premiumatic Authorization on Page 9 is completed and
signed.
Name of Participant ___________________________ Certificate Number _____________
Please attach either 1) a copy of the Payor's check for the initial premium; or
2) a copy of a cancelled check. (Note: Do not send voided check until
certificate is issued.)
1) Complete if payment of initial premium accompanies this form.
Attached is a check, money order, or other (_________________) in the
amount of $__________________
2) Special Comments/Premiumatic Requests:
Firm ____________________________________
Producer _________________________________ Date _______________________
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
DETACH THIS SECTION AND GIVE TO CLIENT
JOHN HANCOCK LIFE INSURANCE COMPANY
Notice to the 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
the 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:
John Hancock Life Insurance Company
P.O. Box 111 John Hancock Place
Underwriting and Issue - Federal Fair Credit Control C-5
Boston, Massachusetts 02117
For identification purposes, your request must include your full name,
birthdate, address, and any applicable certificate number.
- --------------------------------------------------------------------------------
DETACH THIS SECTION AND GIVE TO CLIENT
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.
- --------------------------------------------------------------------------------
Page 13
----------------------------------------
MProprietary Products
[LOGO]
[LOGO]