Exhibit 5 (Form N-4)
Exhibit 4(g)(Form S-1)
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Application For Variable Annuity
ANNUITIES
[LOGO OF John Hancock Funds, Inc.
JOHN HANCOCK Contract Number _____________ John Hancock Servicing Office, P.O. Box 9116, Boston, MA 02205-9116
APPEARS HERE] ---------------------------------------------------------------------------------------------------------------
Participant
__________________________________ __________/_____/_________ ____/____/____ [_]Male
Name Social Security No./Tax ID Date of Birth [_]Female
_______________________________________________________________________________________
Street City State Zip Code
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Joint Participant (spouse only)
__________________________________ __________/_____/_________ ____/____/____ [_]Male
Name Social Security No./Tax ID Date of Birth [_]Female
_______________________________________________________________________________________
Street City State Zip Code
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Annuitant (if other than Participant)
__________________________________ __________/_____/_________ ____/____/____ [_]Male
Name Social Security No./Tax ID Date of Birth [_]Female
_______________________________________________________________________________________
Street City State Zip Code
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Beneficiary Relationship Provisional Date of Maturity:
Guarantee Period ending prior to the Annuitant's
[_] 85th Birthday (Non-Qualified)
[_] 70th Birthday (Qualified) [_] Other age________
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Fund Selection Initial Investment $__________________ Percentages Must be Whole and Total 100%
++++
+ ____% International VA Fund ____% Emerging Equities VA Fund
+ ____% Diversified Core Equity VA Fund ____% Discovery VA Fund
+ ____% Sovereign Investors VA Fund ____% 500 Index VA Fund
+ ____% Sovereign Bond VA Fund ____% Strategic Income VA Fund
+ ____% Global Income VA Fund ____% Money Market VA Fund
+
+ MVA (by Initial Guarantee Period*)
+ ____% 1 Year ____% 2 Years ____% 3 Years ____% 4 Years ___% 5 Years
+ ____% 6 Years ____% 7 Years ____% 8 Years ____% 9 Years ___% 10 Years
++++ *all guarantee periods subject to availability
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Telephone Transfer Option [_] Yes [_]No
I/we 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 change future payment allocations
and/or transfer existing funds among the investment options subject to the provisions of the annuity.
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Tax Qualified Plans
[_] IRA [_] Direct Transfer [_] Rollover [_] Other________________________
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Suitability
[_] I have completed a Client Profile Form and am satisfied that the annuity is suitable as applied for.
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Special Requests Riders
[_] Accidental Death Benefit
[_] One Year Stepped Up-Death Benefit
[_] Waiver of Conditional Deferred Surrender Loads
due to Nursing Home Confinement
[_]Other___________________________________________
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Form 156-JHF1-96
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Additional Premium Payments
Request for Premium Notices: Amount $__________________
[_] Annual [_] Semi-Annual [_] Quarterly [_] Other__________
- - - - Direct Premium Payment Programs
Please [_] I/we authorize John Hancock to begin making automatic monthly
staple withdrawals from my/our account at the financial institution indicated.
your I/we understand that this authorization does not affect the terms of
voided my/our annuity. (Special tax rules apply to IRA contributions.) Monthly
check Amount $___________________
here
- - - - ____________________________________ _______________________________
Financial Institution Account Number
[_] I would like to have my annuity premium payment deducted automatically from
my payroll check. Please send me a payroll deduction authorization form.
[_] I would like to have my annuity premium payment deducted automatically from
my Social Security or Federal Government check. Please submit the Government
Standard Form 1199A to authorize automatic payment into your John Hancock
annuity. Complete Sections A, B, C, and F of the 1199A, and sign. John Hancock
will contact the appropriate government agency on your behalf. For information
about obtaining a Form 1199A, call 1-800-225-5291.
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Replacement Information
Will the Annuity applied for replace or change any existing annuity or life
insurance? [_] Yes [_] No
If yes, Issuer___________________________ Contract Type________________________
Contract Number_________________________________________________________________
[_] 1035 Exchange (please submit cost basis information)
Have you purchased another John Hancock annuity during the previous 12 months?
[_] Yes [_] No
[_] RECEIPT OF A PROSPECTUS IS HEREBY ACKNOWLEDGED. If not checked, a prospectus
will be mailed to you.
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Your Signature(s) and Taxpayer Identification Number Certification
I/we represent: (1) that the number shown on this form is my/our correct
taxpayer identification number, and (2) that I/we are not subject to 31% backup
withholding, either because I/we are exempt from backup withholding, the
Internal Revenue Service has notified me/us that I/we are subject to backup
withholding as a result of a failure to report all interest or dividends, or the
Internal Revenue Service has notified me/us that I/we are no long subject to
backup withholding. (If you are currently subject to backup withholding due to a
Internal Revenue Service notice, strike out clause #2 above.)
I/we acknowledge that I/we have read and completed, as appropriate, all items
contained on this application. I/we understand values and annuity payments which
are based upon investment experience of a seperate account are variable and not
guaranteed as to dollar amount. I/we also acknowledge that the annuity will be
subject to the telephone exchange and loan priviledges described in the Series
Trust's current prospectus (unless indicated otherwise) and agree that the
Series Trust will not be liable for any loss in acting on any written or
telephone instructions that are reasonably believed to be authentic. I/we
further represent that my/our investment objective are the same as those stated
in the current prospectus which I/we have received, read and understood. If this
annuity is for a corporation, business organization or trust, I/we represent
that the individuals signing below have the proper authority to enter into this
contract.
Amounts payable under this certificate may be subject to a Market Value
Adjustment.
______________________________ ______________ __________________ _______
Owner Signature Joint Owner Additional Joint Date
Signature Owner Signature
[_] Check here if you wish a Statement of Additional Information
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Registered Representative Information
Is the annuity applied for intended to replace or change any existing annuity or
life insurance? [_] Yes [_] No
_______________________________________ _____________________________________
Registered Representative (R.R.) Name Firm Name
_______________________________________ _____________________________________
Branch or Agency Number R.R. Number Branch or Agency Address
_______________________________________ _____________________________________
Registered Representative Signature City State ZIP
_______________________________________ _____________________________________
Registered Representative Phone Branch or Agency Phone Extension