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(JOHN HANCOCK(R) LOGO) NOT FOR USE IN NEW YORK
JOHN HANCOCK ANNUITIES
JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.)
[P.O. Box 9505, Portsmouth, NH 03802-9505] (1)
[Overnight mail: 164 Corporate Drive, Portsmouth, NH 03801-6815] (2)
[800-344-1029 www.jhannuities.com] (3)
Home Office: Bloomfield Hills, MI
[MVA Product Application] (4)
SINGLE PAYMENT MODIFIED GUARANTEED DEFERRED ANNUITY
1 EXPECTED INITIAL PREMIUM
Expected Initial Premium Expected initial premium includes any assets coming from another financial institution (i.e., 1035
$ ______________________ exchange, qualified plan rollover, etc.) Amount of actual premium received will appear in the
delivered contract/certificate.
2 OWNER (oldest)
____________________________________________________________________________________ [ ] Male [ ] Female [ ] Trust/Entity
Name (First, Middle, Last or Name of Trust/Entity)
__________________________ _______________________________________________________ ________________________________________
Date of Birth (mm/dd/yyyy) Social Security Number/Tax Identification Number Email Address
____________________________________________________________________________________ ________________________________________
Mailing Address City, State, Zip
____________________________________________________________________________________ ________________________________________
Residential Address (required if different from mailing or address is PO Box) Client Brokerage Account Number
CO-OWNER
____________________________________________________________________________________ [ ] Male [ ] Female [ ] Trust/Entity
Name (First, Middle, Last or Name of Trust/Entity)
__________________________ _______________________________________________________ ________________________________________
Date of Birth (mm/dd/yyyy) Social Security/Tax Identification Number Email Address
____________________________________________________________________________________ ________________________________________
Mailing Address City, State, Zip
____________________________________________________________________________________
Residential Address (required if different from mailing or address is PO Box)
3 ANNUITANT (Applicable for Nonnatural Owners and Nonqualified plans if different from Owner)
____________________________________________________________________________________ [ ] Male [ ] Female [ ] Trust/Entity
Name (First, Middle, Last or Name of Trust/Entity)
__________________________ _______________________________________________________ ________________________________________
Date of Birth (mm/dd/yyyy) Social Security Number/Tax Identification Number Email Address
____________________________________________________________________________________ ________________________________________
Mailing Address City, State, Zip
____________________________________________________________________________________
Residential Address (required if different from mailing or address is PO Box)
CO-ANNUITANT (if different from co-owner)
____________________________________________________________________________________ [ ] Male [ ] Female [ ] Trust/Entity
Name (First, Middle, Last or Name of Trust/Entity)
__________________________ _______________________________________________________ ________________________________________
Date of Birth (mm/dd/yyyy) Social Security Number/Tax Identification Number Email Address
____________________________________________________________________________________ ________________________________________
Mailing Address City, State, Zip
____________________________________________________________________________________
Residential Address (required if different from mailing or address is PO Box)
156-MVA-09 Page 1 of 4 MVAAPPEX 8/09
[MVA Product Application]
4 BENEFICIARIES
If a co-owner was selected in Section 2, the surviving owner will be the primary beneficiary. THE PRIMARY
Contingent beneficiaries receive proceeds only if all primary beneficiaries pre-decease the BENEFICIARIES AND CONTINGENT
owner. If you wish to restrict the death payment options for any of the beneficiaries listed BENEFICIARIES MUST EACH EQUAL
below, please complete the Restricted Beneficiary Payout form located on www.jhannuities.com. 100% OF PROCEEDS. PLEASE USE
WHOLE PERCENTAGES ONLY.
Beneficiary will be the Owner's estate if left blank.
PRIMARY BENEFICIARY CONTINGENT BENEFICIARY (optional)
1 Name: Name:
Relationship: Relationship:
Percentage allocated: _____________ % Percentage allocated: _____________ %
2 Name: Name:
Relationship: Relationship:
Percentage allocated: _____________ % Percentage allocated: _____________ %
NOTE: TO NAME ADDITIONAL BENEFICIARIES, PLEASE USE THE SPACE IN SPECIAL INSTRUCTIONS (SECTION 7).
5 TYPE OF ANNUITY
PLAN TYPE: TAX-QUALIFIED PLANS:
[ ] Qualified [ ] Nonqualified [ ] IRA ________ (Tax Year) [ ] Roth IRA ________ (Tax Year) [ ] IRA Rollover
[ ] IRA Transfer [ ] Other ____________________________________________
6 GUARANTEED PERIOD (PLEASE CHECK ONE. CHECK AVAILABILITY, NOT ALL GUARANTEE PERIODS MAY BE AVAILABLE.)
[ [ ] 3-Year [ ] 5-Year [ ] 7-Year [ ] 10-Year] (5)
7 SPECIAL INSTRUCTIONS (WRITE IN) OR OPTIONAL RIDERS
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[MVA Product Application]
8 ADDITIONAL STATE DISCLOSURES
[FOR APPLICANTS IN ALL STATES EXCEPT AK, AZ, CO, DE, DC, FL, ID, IN, KY, MD, ME, NE, NJ, NM, OH, OK, OR, PA, TN, VA, VT, WA:
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
FOR AK APPLICANTS: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim
containing false, incomplete, or misleading information may be prosecuted under state law.
FOR AZ APPLICANTS: On written request, the Company is required to provide you, within a reasonable time, factual information
regarding the benefits and provisions of your annuity contract. If, for any reason you are not satisfied with your annuity
contract, you may return it within ten days, OR WITHIN THIRTY DAYS IF YOU ARE SIXTY-FIVE YEARS OF AGE OR OLDER ON THE DATE OF
THE APPLICATION FOR YOUR ANNUITY CONTRACT, after the contract is delivered and receive a refund of all monies paid. For your
protection, state law required the following statements to appear on this form. Any person who knowingly presents a false or
fraudulent claim for payment of a loss is subject to criminal and civil penalties.
FOR CO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial
of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false,
incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to
defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to
the Colorado Division of Insurance within the Department of Regulatory Agencies.
FOR DE, ID, IN, OK APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive an insurance company
files a statement of claim containing false, incomplete, or misleading information is guilty of a felony.
FOR DC APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny
insurance benefits if false information materially related to a claim was provided by the applicant.
FOR FL APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY ISSUER FILES A STATEMENT OF
CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
FOR KY, NE, PA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance containing any materially false information or conceals, for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal
and civil penalties.
FOR MD APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit
or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FOR ME, TN, VA, WA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
FOR NJ APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
FOR NM APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal
penalties.
FOR OH RESIDENTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits
an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. (6)
FOR OR, VT RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and
confinement in prison.]
9 MILITARY SALES
Is the annuitant or owner an active member of the U.S. Armed Forces? [ ] Yes* [X] No (default)
* If you answered "Yes", please complete and attach a "Military Personnel Financial Services Disclosure" form (available on
www.jhannuities.com). This product is not specifically designed for or marketed to active duty military personnel. Applications
not complying with our military sales procedures will not be accepted.
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[MVA Product Application]
10 ACKNOWLEDGMENTS/SIGNATURES
STATEMENT OF APPLICANT: I/We agree that the contract/certificate I/we have applied for shall not take effect until the later
of: (1) the issuance of the contract/certificate, or (2) receipt by the company at its Annuity Service Office of the first
payment required under the contract/certificate. The information herein is true and complete to the best of my/our knowledge
and belief and is correctly recorded.
[ ] YES* [ ] NO Does the annuitant or owner have existing individual life insurance policies or annuity contracts?
[ ] YES* [ ] NO Will this contract replace or change any existing life insurance or annuity in this or any other company?
* If you answered "YES" to either question, please complete below and attach a state replacement form (if applicable). Please see
reference guide in the forms booklet.
____________________________________________ ______________________ [ ] Annuity [ ] Life Insurance
Issuing Company Contract Number
I/WE UNDERSTAND THAT UNLESS I/WE ELECT OTHERWISE, THE MATURITY DATE WILL BE THE ANNUITANT'S 95TH BIRTHDAY ALTERNATE MATURITY
DATE_____________________________.
I/WE ACKNOWLEDGE RECEIPT OF THE CURRENT PROSPECTUS AND UNDERSTAND THAT BECAUSE OF THE MARKET VALUE ADJUSTMENT PROVISION OF THE
CONTRACT/CERTIFICATE THE AMOUNT I RECEIVE UPON WITHDRAWAL OR ANNUITIZATION MAY VARY FROM THE REPORTED ACCOUNT VALUE.
I/WE CONFIRM A REVIEW OF MY/OUR INVESTMENT OBJECTIVES, TAX, LIQUIDITY, AND FINANCIAL STATUSES WAS OFFERED TO ME/US.
I/WE HAVE READ THE APPLICABLE FRAUD STATEMENT CONTAINED IN THE STATE DISCLOSURES SECTION.
TO THE BEST OF MY KNOWLEDGE AND BELIEF, THE STATEMENTS IN THIS APPLICATION ARE TRUE AND COMPLETE.
I/WE AM/ARE EITHER A CITIZEN OR RESIDENT ALIEN OF THE UNITED STATES OF AMERICA.
SIGN
HERE OWNER: -------------------------------------------- ____________________________________ __________
Signature City, State (signed in) Date
SIGN
HERE CO-OWNER: -------------------------------------------- ____________________________________ __________
Signature City, State (signed in) Date
SIGN ANNUITANT: -------------------------------------------- ____________________________________ __________
HERE (If different from owner) Signature City, State (signed in) Date
SIGN CO-ANNUITANT: -------------------------------------------- ____________________________________ __________
HERE (If different from co-owner) Signature City, State (signed in) Date
11 FINANCIAL ADVISOR INFORMATION
A. CERTIFICATION: I HAVE TRULY AND ACCURATELY RECORDED THE INFORMATION PROVIDED BY THE APPLICANT AND I HAVE DETERMINED THAT
THE ANNUITY CONTRACT/CERTIFICATE APPLIED FOR IS A SUITABLE INVESTMENT FOR THE APPLICANT.
[ ] YES [ ] NO Does the annuitant or owner have existing individual life insurance policies or annuity contracts?
[ ] YES [ ] NO Will this contract/certificate replace or change any existing life insurance or annuity in this or any other
company?
[B. OPTION [ ] A [ ] B [ ] C (If left blank, option will default to your firm's Selling Agreement.)] (7)
IF YES, COMPLETE APPLICABLE STATE REPLACEMENT FORMS.
__________________________________________________ ________________________________________ _______________________________
Printed name Telephone Number State License ID
__________________________________________________ ________________________________________ _______________________________
SIGN Broker/Dealer Firm Broker/Dealer Rep Number Email Address
HERE
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Signature
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