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EXHIBIT (A)(10)(a)

APPLICATION FOR FLEXIBLE PREMIUM
VARIABLE LIFE INSURANCE

THE MANUFACTURERS
LIFE INSURANCE COMPANY
OF NEW YORK

[LOGO]

MANULIFE FINANCIAL
THE MANUFACTURERS LIFE INSURANCE
COMPANY OF NEW YORK

Manulife Financial and the block design are registered service marks of The
Manufacturers Life Insurance Company and are used by it and its subsidiaries.
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[LOGO]

MANULIFE FINANCIAL
THE MANUFACTURERS LIFE INSURANCE
COMPANY OF NEW YORK

Application for Flexible Premium Variable Life Insurance To
THE MANUFACTURERS LIFE INSURANCE COMPANY OF NEW YORK
(hereinafter referred to as The Company)

APPLICATION NO.
PLEASE PRINT & USE BLACK INK. ANY CHANGES MUST BE
INITIALLED BY THE PROPOSED INSURED AND/OR OWNER. POLICY NO.

PROPOSED LIFE INSURED:

1a. Name (first, middle, last) 1b. Date of Birth (mmm/dd/yyyy) 1c. Place of Birth 1d. Soc. Sec.No./Tax I.D. No.

1e. Sex 1f. Occupation 1g. Specific Duties 1h. How Long?

1i. Home Address City State Zip 1j. How Long?

1k. Employer Name and Address City State Zip 1l. How Long?

OWNER IF OTHER THAN PROPOSED LIFE INSURED:

2a. Name (first, middle, last)
2b. Date of Birth (mmm/dd/yyyy) 2c. Occupation 2d. Relationship to Proposed Life Insured
2e. Address City State Zip
2f. Employer Name and Address City State Zip
2g. If home address or employer has changed in last 2 years, give details:

SUCCESSOR OWNER - RECOMMENDED FOR JUVENILE INSURANCE - NOT RECOMMENDED FOR BUY-SELL OR CORPORATE-OWNED
3a. Name 3b. Relationship to Owner 3c. Soc. Sec. No./Tax I.D. No.

BENEFICIARY(IES) SUBJECT TO CHANGE BY OWNER:

4a. Primary 4b. Relationship to Proposed Life Insured
4c. Secondary 4d. Relationship to Proposed Life Insured

SEND PREMIUM NOTICES TO:

5a. / / Insured / / Owner / / Business / / Residence / / Other(give details below):
5b. Name Address City State Zip

LIFE INSURANCE IN FORCE:
6a. Total insurance in force on the Proposed Life Insured's life $_________
6b. Total insurance currently pending with all companies, including this
application $__________________. Of this total, what amount of
insurance do you intend to accept? $__________________________________
6c. LIST POLICIES IN FORCE

Year of Accidental GI Option (X)
COMPANY Issue Group? Face Amount Death Amount Business Personal
------- ----- ------ ----------- ----- ------ -------- --------

7. Have you ever been declined for insurance, or been offered insurance YES NO
with restricted benefits or at other than standard rates? / / / /

8. Is this insurance to replace, or will it cause a change in, or involve
a loan under, any insurance or annuity policy on any Proposed Life
Insured's life or in any insurance or annuity policy owned by the
Owner? IF "YES", TO EITHER 7 OR 8, GIVE DETAILS BELOW: / / / /

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Manulife Financial and the block design are registered service marks of The
Manufacturers Life Insurance Company and are used by it and its subsidiaries.
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APPLICATION NO. PLEASE PRINT

POLICY APPLIED FOR

9a. Plan (non-participating):
9b. Face Amount (policy only, excluding Supplementary Benefits): $
9c. If an additional or optional policy is being applied for in a separate
application, state plan and amount.

9d. Loan Interest Rate (Check /X/ loan rate applicable to the policy being
applied for) / / 5.75% / / 8% / / Variable
9e. If a supplementary benefit applied for cannot be approved, should the
policy be issued without it? / / Yes / / NO / / Not Applicable
9f. Is a policy guarantee being applied for?
/ / Yes / / No / / Not Applicable
If "Yes", indicate type of policy guarantee: / / No Lapse Guarantee
/ / Death Benefit Guarantee

SUPPLEMENTARY BENEFITS

SINGLE-LIFE PLANS SURVIVORSHIP PLANS

10. / / Total Disability Waiver of Monthly Deductions 11. / / Policy Split Option
/ / Guaranteed Policy Value / / Four Year Term (EPR)
/ / Additional Life (number of lives maximum 6) / / Other (State which)
/ / Other (State which)

PREMIUMS

11a. Frequency / / Annual / / Semi / / Quarterly / / Monthly
11b. If monthly / / Manumatic Transfer
11c. Planned Premium $
11d. Additional "once only" premium $
11e. Amount paid with application $

DEATH BENEFIT

12. / / Option 1: Face Amount / / Option 2: Face Amount Plus Policy Value

SPECIAL REQUESTS

13.

HOME OFFICE NOTES

14.

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APPLICATION NO. PLEASE PRINT

SMOKING QUESTIONS

YES NO

15a. Have you used tobacco in any form during the past 2 years (including / / / /
cigars, cigarillos, a pipe, chewing tobacco or cigarettes)? If "Yes"
what type of tobacco?

15b. Do you use any medication or product containing nicotine? If "Yes", / / / /
give details:

15c. Have you smoked any cigarettes during the past 12 months? If "Yes", how
many? / / / /

15d. Were you previously a cigarette smoker but have now stopped? / / / /
If "Yes", when did you stop? Give month and year:

AVOCATION QUESTIONS
YES NO
16a. Do you have any part-time or seasonal occupation? / / / /

16b. Do you expect to change your occupation? / / / /

16c. Do you expect to change your country of residence? / / / /
If "Yes", give details:

17a. Have you flown as a student pilot, licensed pilot or crew member in any
aircraft (including ultralight planes) in the past 2 years? / / / /

17b. Are any such flights planned in the future? / / / /

17c. Have you engaged in any form of motor vehicle or power boat racing, sky
diving, skin or scuba diving, parachuting, hang-gliding, mountain
climbing or ballooning in the last 2 years? / / / /

18a. What is your Drivers License Number? State / / / /

18b. Have you been convicted of 3 or more moving violations within the past
3 years? / / / /

18c. Have you been convicted of driving while intoxicated or while otherwise
impaired? If "Yes", give details. / / / /

FINANCIAL QUESTIONS

COMPLETE WHEN AMOUNT OF INSURANCE IS $250,000 AND MORE, OR WHEN APPLYING FOR
BUSINESS INSURANCE FOR ANY AMOUNT, OR INSURANCE ON THE LIFE OF A JUVENILE FOR
ANY AMOUNT.

19. What is the purpose of this insurance? (e.g. estate conservation,
buy-sell, keyman)

20. How was the need for this amount determined? (Please submit copies of
financial statement(s), estate analysis, contractual agreements, etc.)

21a. Gross annual earned income (salary, commissions, bonuses, etc.) $

21b. Gross annual unearned income (dividends, interest, net real estate
income, etc.) $

21c. Total Assets $ 21d. Total Liabilities? $ 21e. Personal Net Worth?$

JUVENILE INSURANCE:

22a. Are all brothers and sisters equally insured? / / Yes / / No
If "No", give details:

22b. Are parent(s)/guardians covered by life insurance? / / Yes / / No
If "Yes", how much is in force?
If "No", why not?

22c. Occupation or other independent source of income of proposed Life
Insured, if applicable:

BUSINESS INSURANCE: Provide the following information on your company

Current Year Previous Year

23a. Assets $ $

23b. Liabilities $ $

23c. Gross Sales $ $

23d. Net Income after taxes $ $

23e. Fair Market Value of the business $

23f. What percentage of the business is owned by the proposed Life Insured? %

23g. Are other partners/owners/executives being insured? Give details:

24. In the past 5 years, has the Proposed Life Insured or the business had
any major financial problems (bankruptcy,etc.)? / / Yes / / No
If "Yes", give details:

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APPLICATION NO. PLEASE PRINT

MEDICAL QUESTIONS-PLEASE PROVIDE DETAILS TO "YES" ANSWERS IN THE SPACE BELOW

25. Have 2 or more of your immediate family members (parents, brothers and
sisters) prior to age 65, died of or been diagnosed as having coronary
artery disease, stroke or kidney disease? / / Yes / / No

26. FAMILY HISTORY L AGE GIVE DETAILS OF PRESENT HEALTH D AGE CAUSE OF DEATH
I E
Father V C
Mother I E
Brothers N A
and G S
Sisters E
D

27a. Your Height 27b. Your Weight 27c. Any weight loss in the last year? / / Yes / / No

28a. Name and address of personal or attending doctor: 28b. Date last consulted?
28c. Reason and any medication/treatment given:

28d. List any medications you are taking currently:

YES NO

29. SO FAR AS YOU KNOW, WITHIN THE LAST 10 YEARS HAVE YOU EVER BEEN
DIAGNOSED BY A MEMBER OF THE MEDICAL PROFESSION AS HAVING:

a.) Chest pain, shortness of breath, heart murmur, high blood pressure,
stroke, irregular heart beat, or any other disease or disorder of the
heart or arteries? / / / /
b.) Diabetes or disease of any glands? / / / /
c.) Mental or emotional disorder, nervous breakdown, convulsions, epilepsy,
paralysis or any other disorder of the brain or nervous system? / / / /
d.) Arthritis, gout, or any bone, joint, muscle or skin disorder? / / / /
e.) Asthma, bronchitis, pneumonia, emphysema or any lung disorder? / / / /
f.) Cirrhosis, hepatitis, ulcer, colitis, diverticulitis, ileitis, or other
disease of the liver, gall bladder, pancreas, stomach or intestines? / / / /
g.) Prostate or testicular disease, disease of the uterus, ovaries or
breast? / / / /
h.) Anemia, leukemia, clotting disorders, platelet disorders, infections,
or sources of blood loss? / / / /
i.) Disorder of the urinary tract or kidneys - sugar, albumin or blood in
the urine? / / / /
j.) Cancer or tumors? / / / /
k.) An operation or admission to a hospital or any other health care
facility for observation, treatment of any illness or diagnostic tests,
including treadmill stress test for insurance (excluding an HIV test)? / / / /
l.) Any other health impairment or medically treated condition? / / / /
m.) Treatment or advice from a physician, or licensed practitioner,
regarding alcohol or drug use? / / / /
30. Within the last 10 years have you been diagnosed by a member of the
medical profession as having Acquired Immune Deficiency Syndrome (AIDS)
or AIDS Related Complex (ARC)? / / / /

PLEASE PROVIDE DETAILS TO ANY "YES" ANSWERS (IF MORE SPACE IS REQUIRED, USE THE
MEDICAL QUESTIONS CONTINUATION SHEET)

QUESTION NAME, ADDRESS AND PHONE NO. OF DURATION
NUMBER DATE ATTENDING DOCTOR AND HOSPITAL OF CONDITION REASON AND ANY TREATMENT GIVEN
- ------ ---- ----------------------------- ------------ ------------------------------

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APPLICATION NO.

REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION
(TO BE COMPLETED BY OWNER/TAXPAYER)

In order to comply with IRS regulations regarding Tax Identification Numbers and Social Security Number
Backup Tax Withholding, individuals and sole proprietors MUST give their Social
Security Number. Other entities MUST give their Employer Identification Number.

If you have no number or you have applied for a number and are waiting for one Employer Identification Number
to be issued, write "APPLIED FOR" in the boxes. You then have 60 days to supply
your TIN number to us. After 60 days, The Company must begin Backup Tax
Withholding.

CERTIFICATION - UNDER PENALTIES OF PERJURY, I CERTIFY THAT:

(1) The number shown on this form is my correct taxpayer identification
number (or I am waiting for a number to be issued to me), AND

(2) I am not subject to Backup Tax Withholding either because I have not
been notified by the Internal Revenue Service (IRS) that I am subject
to Backup Tax Withholding as a result of a failure to report all
interest or dividends, or the IRS has notified me that I am no longer
subject to Backup Tax Withholding (does not apply to real estate
transactions, mortgage interest paid, the acquisition or abandonment of
secured property, contributions to an individual retirement arrangement
(IRA), and payments other than interest and dividends).

CERTIFICATION INSTRUCTIONS - You MUST cross out item (2) above if you have been
notified by the IRS that you are currently subject to Backup Tax Withholding
because of underreporting interest or dividends on your tax return.

Signed at ____________________________ this ______ day of ___________ __________
City / State Month Year

(X)____________________________________
SIGNATURE OF OWNER / TAXPAYER

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APPLICATION NO.

SIGNATURES

THE PROPOSED LIFE INSURED (OR PARENT OR GUARDIAN) HAS READ THE STATEMENTS AND
ANSWERS TO THE MEDICAL EVIDENCE PORTION AND THEY ARE COMPLETE AND TRUE TO THE
BEST OF HIS/HER KNOWLEDGE AND BELIEF. THE PROPOSED LIFE INSURED HEREBY AGREES
THAT THEY SHALL FORM PART OF THE APPLICATION FOR LIFE INSURANCE FOR WHICH SUCH
MEDICAL EVIDENCE WAS REQUIRED BY THE COMPANY.

THE PROPOSED LIFE INSURED (OR PARENT OR GUARDIAN) ACKNOWLEDGES RECEIPT OF THE
NOTICE OF DISCLOSURE OF INFORMATION.

THE PROPOSED LIFE INSURED AND OWNER (OR PARENT OR GUARDIAN) AGREE THAT: 1.) THE
STATEMENTS AND ANSWERS IN THIS APPLICATION ARE COMPLETE AND TRUE TO THE BEST OF
THEIR KNOWLEDGE AND BELIEF. 2.) UNLESS THE TERMS AND CONDITIONS OF THE TEMPORARY
LIFE INSURANCE AGREEMENT ARE SATISFIED SO THAT INSURANCE IS PROVIDED UNDER THAT
AGREEMENT, INSURANCE UNDER ANY POLICY ISSUED ON THE APPLICATION WILL BECOME
EFFECTIVE ONLY WHEN THE FIRST PREMIUM HAS BEEN PAID IN FULL AND THE POLICY HAS
BEEN DELIVERED; PROVIDED THAT AT THE TIME OF DELIVERY THERE HAS BEEN NO
DETERIORATION IN THE INSURABILITY OF ANY PERSON PROPOSED FOR LIFE INSURANCE AS
STATED IN THE APPLICATION, SINCE THE DATE OF THE APPLICATION. THEY ARE AWARE THE
COMPANY HAS UNDERWRITING RULES TO DETERMINE INSURABILITY.

THE PROPOSED LIFE INSURED AND OWNER (OR PARENT OR GUARDIAN) UNDERSTAND THAT
UNDER THE POLICY APPLIED FOR, THE AMOUNT OF THE INSURANCE BENEFITS, THE DURATION
OF THE INSURANCE COVERAGE, AND THE POLICY VALUE MAY INCREASE OR DECREASE
DEPENDING ON THE INVESTMENT EXPERIENCE OF THE CHOSEN INVESTMENT ACCOUNT AND ARE
NOT GUARANTEED AS TO DOLLAR AMOUNT. ILLUSTRATIONS OF BENEFITS, INCLUDING DEATH
BENEFITS, POLICY VALUES AND CASH SURRENDER VALUES ARE AVAILABLE UPON REQUEST.

Signed at ____________________________ this ______ day of _____________ ________
City / State Month Year

(X)___________________________________ (X)______________________________________
WITNESS SIGNATURE OF PROPOSED LIFE INSURED

(X)___________________________________ (X)______________________________________
WITNESS SIGNATURE OF OWNER, IF OTHER THAN
PROPOSED LIFE INSURED

(X)___________________________________ (X)______________________________________
WITNESS SIGNATURE OF ANY PROPOSED JUVENILE
LIFE INSURED OVER AGE 10

(X)___________________________________ (X)______________________________________
SIGNATURE OF REGISTERED REPRESENTATIVE CONSENT OF PARENT OR GUARDIAN, IF OTHER
IF OTHER THAN WITNESS THAN OWNER
/ / FATHER / / MOTHER / / GUARDIAN

All other Registered Representatives sharing commissions for this policy must
also sign here.

(X)___________________________________ (X)______________________________________
SIGNATURE OF REGISTERED REPRESENTATIVE PLACE AND DATE

(X)___________________________________
COUNTERSIGNATURE OF LICENSED RESIDENT AGENT
(WHERE REQUIRED BY LAW)

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APPLICATION NO. PLEASE PRINT

TO BE ANSWERED BY THE REGISTERED REPRESENTATIVE (REQUIRED FOR ALL APPLICATIONS)

1. If the Owner is a Corporation, Partnership, Trust or other legal
entity, the NASD requires such entity to provide The Company with
documentation detailing the name(s) of all individuals authorized to
transact business on behalf of the entity. This requirement will be
satisfied by submitting a copy of the Corporation Resolution,
Partnership Agreement, or Certification by Trustee form.

List the name(s) of individual(s) authorized to transact business on
behalf of the entity:

2. Temporary Life Insurance Agreement Issued? / / Yes / / No

3. TO THE BEST OF YOUR KNOWLEDGE, IS THIS INSURANCE INTENDED TO REPLACE,
OR WILL IT CAUSE A CHANGE IN, OR INVOLVE A LOAN UNDER, ANY INSURANCE OR
ANNUITY POLICY ON THE LIFE OF ANY PROPOSED LIFE INSURED OR IN ANY
INSURANCE OR ANNUITY POLICY OWNED BY THE OWNER? / / YES / / NO

IF "YES", GIVE DETAILS AND COMPLETE ANY REPLACEMENT FORMS THAT ARE
REQUIRED. ADVISE WHETHER ANY POLICY BEING REPLACED WAS ITSELF A
REPLACEMENT POLICY WITHIN THE PAST 5 YEARS.

4. Is this a 1035 exchange? / / Yes / / No
If "Yes", how many policies will be exchanged?

LIST POLICIES:

Type of Contract
Company Name Policy No. (Annuity, Life, Term, Annuitant / Insured Owner
Endowment)

5. Additional information to be used in assessing suitability. (Please
give explanation if annual premium is more than 3% of annual income, if
spouse's income is to be included in determining suitability, if
answers to income and net worth have not been provided, etc.):

6. If you are sharing the commissions for this policy with another
agent(s) or entity(ies), please complete the following:

NAME OF AGENT / ENTITY AGENT CODE SHARE REMARKS

TOTAL 100%

I certify that I have truly and accurately recorded on the application all the
information supplied by the Proposed Life Insured (or Parent or Guardian).

I CERTIFY THAT A CURRENT PROSPECTUS (AND ANY SUPPLEMENT) FOR THE POLICY APPLIED
FOR HAS BEEN GIVEN TO THE PROPOSED LIFE INSURED, AND TO THE OWNER IF OTHER THAN
THE PROPOSED LIFE INSURED, AND THAT NO SALES MATERIALS OTHER THAN THOSE APPROVED
BY THE APPROPRIATE REGULATING AUTHORITIES HAVE BEEN USED.

(X)_____________________________________ (X)____________________________________
SIGNATURE OF REGISTERED REPRESENTATIVE Place and Date

All other Registered Representatives sharing commissions for this policy must
also sign here.

(X)_____________________________________ (X)____________________________________
SIGNATURE OF REGISTERED REPRESENTATIVE Place and Date

OFFICE Has this application been approved by the Office of Supervisory Jurisdiction? / / Yes / / No
SUPERVISORY If answer is "Yes", Office of Supervisory Jurisdiction approval date is:
JURISDICTION If answer is "No", explain:

_________________________________ _____________________________________ ____________________ _____
NAME OF BROKER/DEALER REGISTERED PRINCIPAL SIGNATURE DATE (Month / Day / Year)

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[LOGO] -----------------------------------------------------
THE MANUFACTURERS LIFE Notice Regarding Temporary Life Insurance Agreement
INSURANCE COMPANY OF and Receipt
NEW YORK
THE MANUFACTURERS LIFE INSURANCE COMPANY OF NEW YORK
(hereinafter referred to as The Company)
DO NOT DETACH
- --------------------------------------------------------------------------------
Application No. Policy No. Name of Proposed Life Insured

- --------------------------------------------------------------------------------
HEALTH QUESTIONS.
HAS THE PROPOSED LIFE INSURED UNDER THIS APPLICATION:
YES NO
(a) WITHIN THE LAST 12 MONTHS BEEN TREATED OR HAD TREATMENT
RECOMMENDED BY A MEMBER OF THE MEDICAL PROFESSION FOR ANY
HEART PROBLEM, STROKE, CANCER OR PNEUMONIA?......................... / / / /
(b) WITHIN THE LAST 60 DAYS HAD OR BEEN ADVISED TO HAVE ANY ADDITIONAL
MEDICAL DIAGNOSTIC TEST, TREATMENT OR SURGERY NOT YET PERFORMED
(EXCLUDING AN HIV TEST)?............................................ / / / /
(c) WITHIN THE LAST 2 YEARS, BEEN DECLINED FOR LIFE OR DISABILITY INCOME
INSURANCE?.......................................................... / / / /

If any of questions (a), (b), or (c) above is answered "Yes" or left blank, or
if the Proposed Life Insured is under 15 days of age or over age 70 (nearest
birthday) as at the date below, do not pay any money as no coverage will be
provided under the Temporary Insurance Agreement.

I have read and understand the terms and conditions of the Temporary Life
Insurance Agreement. The Proposed Life Insured agrees that to the best of
his/her knowledge and belief the answers to the above Health Questions are true.

Signed at this day of
--------------------------------- --- -------------- -----
City/State Month Year

(X) (X)
- ---------------------------------- ------------------------------------------
WITNESS SIGNATURE OF PROPOSED LIFE INSURED

(X) (X)
- ---------------------------------- -----------------------------------------
WITNESS SIGNATURE OF OWNER (IF OTHER THAN
PROPOSED LIFE INSURED)

(X) (X)
- ---------------------------------- -------------------------------------------
WITNESS SIGNATURE OF PARENT OR GUARDIAN (IF MINOR
CHILD IS PROPOSED LIFE INSURED)
- --------------------------------------------------------------------------------
[BAR CODE]
Manulife Financial and the block design are registered service marks of The
Manufacturers Life Insurance Company and are used by it and its subsidiaries.

................................................................................
DETACH AND GIVE TO OWNER
[LOGO] -----------------------------------------------------
THE MANUFACTURERS LIFE Temporary Life Insurance Agreement and Receipt
INSURANCE COMPANY OF THE MANUFACTURERS LIFE INSURANCE COMPANY OF NEW YORK
NEW YORK (hereinafter referred to as The Company)

The Company acknowledges receipt of $ as a premium for life
-------------
insurance applied for on the life of
-------------------------------------------

for Application number
---------------------------------------------------------

(X)
- ---------------------------------- -------------------------------------------
Date Signature of Agent or Registered
Representative

ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO THE COMPANY AND ADDRESSED TO: P.O.
BOX 40, BUFFALO, NEW YORK 14240-0040.

The Company will pay a death benefit to the beneficiary named in the
Application if any Proposed Life Insured dies while this Agreement is in
effect, subject to the terms and conditions set out below.

1. LIMITED AMOUNT OF INSURANCE. THE AMOUNT OF COVERAGE UNDER THIS AGREEMENT WILL
BE THE LESSER OF: (a) THE AMOUNT OF INSURANCE APPLIED FOR INCLUDING ANY
SUPPLEMENTARY BENEFITS AND ACCIDENTAL DEATH BENEFIT IF THE PROPOSED LIFE
INSURED'S DEATH IS CAUSED BY AN ACCIDENT; AND (b) $1,000,000 ($200,000 FOR
JUVENILE INSURANCE). THIS MAXIMUM AMOUNT OF COVERAGE APPLIES TO THE TOTAL
AMOUNT UNDER THIS AGREEMENT AND ANY OTHER TEMPORARY LIFE INSURANCE AGREEMENT
WITH THE COMPANY COVERING THE PROPOSED LIFE INSURED. IF THERE ARE TWO OR MORE
PERSONS PROPOSED FOR INSURANCE, THIS MAXIMUM AMOUNT APPLIES TO THE TOTAL
COVERAGE.
(See Over)
- --------------------------------------------------------------------------------
ManuLife Financial and the block design are registered service marks of The
Manufacturers Life Insurance Company and are used by it and its subsidiaries.

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2. ACCIDENTAL DEATH BENEFIT LIMITATION. If the benefits applied for include an
accidental death benefit, no such benefit will be paid in respect of a
death caused by: (a) voluntarily taking or absorbing of any drug, medicine,
sedative or poison (except in connection with any Proposed Life Insured's
employment) unless prescribed by a licensed doctor other than the Proposed
Life Insured; (b) suicide whether sane or insane or (c) travel in any
aircraft other than as a passenger.

3. TEMPORARY LIFE INSURANCE AGREEMENT. If any questions (a), (b), or (c) in
the Notice Regarding Temporary Life Insurance Agreement and Receipt is
answered "yes" or left blank, no money will be accepted and no coverage
will be provided under this Agreement.

4. DATE INSURANCE BEGINS. Insurance under this Agreement will begin on the
date of this Agreement if The Company's Application for Life Insurance has
been completed and a payment has been received by The Company for at least
one-twelfth of the annual premium for the basic plan and any riders or
supplementary benefits requested in the Application. If payment is made by
check or draft, no insurance will be provided by this Agreement unless the
check or draft is honored when first presented for payment.

5. DATE INSURANCE ENDS -- 90 DAY MAXIMUM. Insurance under this Agreement will
end on the earliest of: (a) the 90th day after the date of this Agreement;
(b) the day before the date insurance takes effect under the policy applied
for; (c) the date The Company offers insurance other than as applied for;
or (d) the date 5 days after the Company mails notice to the applicant that
the Application is declined and refunds the premium paid.

6. SUICIDE. If any person proposed for insurance, commits suicide, The Company
will only be liable for a refund of the premium paid.

7. MISREPRESENTATION. If there is any material misrepresentation in the
answers to the Health Questions in the Notice Regarding Temporary Life
Insurance Agreement and Receipt, the Application or in any Medical Evidence
Exam form submitted to The Company related to any Proposed Life Insured,
The Company will only be liable for a refund of the premium paid.

8. OTHER CONDITIONS. No one is authorized to: (a) accept any premium for any
Proposed Life Insured under 15 days of age or over age 70 (nearest
birthday) as at the date of this Agreement; or (b) change or waive any
provision of this Agreement.

THE ABOVE EXCLUSIONS APPLY EXCEPT AS OTHERWISE PROVIDED BY APPLICABLE STATE
LAW.
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[MANULIFE FINANCIAL LOGO] -----------------------------------------------------
Authorization To Obtain Information

THE MANUFACTURERS LIFE INSURANCE COMPANY OF NEW YORK
(hereinafter referred to as The Company)

APPLICATION NO.

I hereby give permission to any physician, medical care provider, hospital,
clinic, laboratory, insurance company or MIB Inc. (The Medical Information
Bureau) or any other similar person or organization to give The Company and to
its reinsurers, information about me or any of my minor children who are to be
insured. The information collected by The Company may relate to the symptoms,
examination, diagnosis, treatment or prognosis of any physical or mental
condition. Although information related to drug or alcohol abuse is protected
from disclosure by Federal Regulation 42 CFR Part 2, I give permission to The
Company to collect this information for those purposes which are described
below. I understand that I can revoke this permission to collect information
related to drug or alcohol abuse at any time, but any revocation will not
affect such information that has already been collected and relied on by The
Company. I authorize The Company to obtain an investigative consumer report on
me. Information collected under this Authorization will be used by The Company
to evaluate my application for insurance, to evaluate a claim for benefits, or
for reinsurance or other insurance purposes. I understand that I have a right
to receive a copy of this form. I agree that a photocopy of this form will be
as valid as the original. This Authorization will be valid for two years from
the date shown below. I acknowledge receipt of the Notice of Disclosure of
Information.

Date (mmm/dd/yyyy) (X)
--------------------- -------------------------------------
SIGNATURE OF PROPOSED LIFE INSURED

Names of minor child(ren) proposed
for insurance (X)
------------------------ --------------------------------------
WITNESS
- ---------------------------------------- (X)
--------------------------------------
SIGNATURE OF PARENT OR GUARDIAN (IF
MINOR CHILDREN PROPOSED FOR
INSURANCE)
- --------------------------------------------------------------------------------
[BAR CODE]
ManuLife Financial and the block design are registered service marks of The
Manufacturers Life Insurance Company and are used by it and its subsidiaries.

Form NB4116NY(1097)
................................................................................
DETACH AND GIVE TO PROPOSED LIFE INSURED
[MANULIFE FINANCIAL LOGO] -----------------------------------------------------
Notice of Disclosure of Information

THE MANUFACTURERS LIFE INSURANCE COMPANY OF NEW YORK
(hereinafter referred to as The Company)

APPLICATION NO.
This brief description of our underwriting process is designed to help you
understand how an application for life insurance is handled, the types and
sources of information we may collect about you, the circumstances under which
we may disclose that information to others and your right to learn the nature
and substance of that information upon written request. The purpose of the
underwriting process is to make sure that you qualify for life insurance under
the rules of The Company and, assuming you do, establish the proper premium
charge for that insurance. The underwriting process assures that the cost of
insurance is distributed equitably among all policyowners, and that each
individual pays his or her fair share. The information necessary to evaluate
your application is dependent upon your age, the amount of insurance you are
applying for, your medical history, your occupation, your avocations and other
personal information. Your answers on the application are the principal source
of information, however additional sources of information may be required.

Information given in your application may be made available to other insurance
companies to which you make application for life or health insurance coverage
or to which a claim is being submitted. Information you provide will be treated
as confidential. The Company may, however, make a brief report thereon to the
MEDICAL INFORMATION BUREAU (M.I.B.), a non-profit membership organization of
life insurance companies which operates an information exchange on behalf of
its members. Upon request by another member insurance company to which you have
applied for life or health insurance coverage or to which a claim is submitted,
M.I.B. will supply such company with the information it may have in its files.
Upon receipt of a request from you, the Bureau will arrange disclosure of any
information it may have in your file. (Medical information will be disclosed
only to your attending physician). If you question the accuracy of information
in the Bureau's file, you may contact the Bureau and seek a correction in
accordance with the procedures set forth in the Federal Fair Credit Reporting
Act. THE ADDRESS OF THE BUREAU'S INFORMATION OFFICE IS POST OFFICE BOX 105,
ESSEX STATION, BOSTON, MASSACHUSETTS 02112; TELEPHONE NUMBER (617) 426-3660.
The Company may also release information in its file to other life insurance
companies to whom you may apply for life or health insurance, or to whom a
claim for benefits may be submitted. As part of our normal procedure, an
investigative consumer report may be prepared concerning character, general
reputation, personal characteristics and mode of living, except as may be
related directly or indirectly to your sexual orientation. This information
will be obtained through a personal interview and/or interviews with friends,
neighbors and associates. On request to the SENIOR UNDERWRITING CONSULTANT, THE
MANUFACTURERS LIFE INSURANCE COMPANY OF NEW YORK, P.O. BOX 40, BUFFALO, NEW
YORK 14240-0040, we will disclose to you whether or not a consumer report was
done. We will give you the name and address of the consumer reporting firm so
that you may request a copy of the report.
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ManuLife Financial and the block design are registered service marks of The
Manufacturers Life Insurance Company and are used by it and its subsidiaries.
12

[LOGO]
MANULIFE FINANCIAL
THE MANUFACTURERS LIFE INSURANCE
COMPANY OF NEW YORK

GENERAL AVOCATION QUESTIONNAIRE

THE MANUFACTURERS LIFE INSURANCE COMPANY OF NEW YORK
(hereinafter referred to as The Company)

APPLICATION NO.

ANSWER ONLY THOSE QUESTIONS WHICH RELATE TO THE ACTIVITIES OF THE PROPOSED
INSURED.
A SIGNATURE IS REQUIRED ON THE REVERSE IF ANY OF THE QUESTIONS ARE ANSWERED.

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Proposed Life Insured Name Policy Number

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Hang Gliding Questions
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1. How frequently do you hang glide?

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2. Are you a member of an organized club? / / Yes / / No Do you hang glide professionally? / / Yes / / No
How high do you usually fly?____________ feet
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3. What is the greatest height _____________ distance ___________________ duration ___________________________________ flown?
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4. Have you or do you intend to attempt any height, distance, or duration records? / / Yes / / No If "Yes" give details:

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5. Have you ever flown or do you intend to fly experimental hang gliding equipment of either a manufacturer's or your own design?
/ / Yes / / No If "Yes" give details:
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Sky Diving Questions
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1. How long have you been sky diving? ________ years. Are you a member of a recognized Parachute Club? / / Yes / / No
If "Yes" give details:
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2. How many jumps (a) have you made in the last 12 months? ______________ (b) did you make 12 to 24 months ago? _________________
(c) do you expect to make in the next 12 months? _______________
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3. From what altitude do you normally jump? __________________ feet
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4. Do you participate in sky diving exhibitions and/or competitions? / / Yes / / No If "Yes" give details:

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5. Do you receive remuneration for sky diving activity? / / Yes / / No If "Yes" give details:

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6. Are you a member of a military parachutist organization? / / Yes / / No If "Yes" give details:

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Organized Automobile and Motorcycle Racing Questions
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1. Do you engage in organized automobile racing? / / Yes / / No Organized Motorcycle racing? / / Yes / / No
Type of vehicle used in races:
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2. How many races did you enter in the last 12 months? _________ The last 12 to 24 months? _________ Next 12 months? ________
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3. What is the maximum speed attained? _______________ 4. The average speed? ______________
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5. If drag racing, elapsed time ________________
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6. What class of racing or competition do you engage in? (e.g.: Automobile - midget, sports car, stock car, championship, drag,
sprint, etc. Motorcycle - hill climbing, cross country, drag, track)

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7. Indicate type of track and surface used:
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8. Purpose of racing: / / Professional / / Amateur / / Both (give details):

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9. Have you ever done or do you intend to do any stunt driving? / / Yes / / No If "Yes" give details:

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10. Have you had any accidents related to driving? / / Yes / / No If "Yes" give details:
(See Over)
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[BAR CODE]

Manulife Financial and the block design are registered service marks of The
Manufacturers Life Insurance Company and are used by it and its subsidiaries.
13

Aviation Questions

1. Flying time as pilot: (a) Number of hours flown in command ________ hours
(b) Date of last flight _________________________________________________
(c) Type of license currently held [] Student [] Private [] Commercial
[] Senior Commercial [] ATR
(d) Do you hold a valid instrument rating? [] Yes [] No
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2. As pilot, student or air crew on nonscheduled flights:
Number of hours flown in last 12 months _____ hours
Last 12-24 months _____ hours
Next 12 months _____ hours
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3. Purpose of Flying (Present and Future) [] Pleasure [] Commercial
[] Military [] Business
[] Other (give details):

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4. Category, class and type of aircraft flown:

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5. Have you ever had an accident, been grounded, fined or reprimanded for
violation of air regulations? [] Yes [] No If "Yes" give details:

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6. Do you engage or expect to engage in charter flying, freight transport,
instructing, testing, crop-dusting, survey and patrol, sightseeing,
photography?
[] Yes [] No [] Other If "Yes" or "Other" give details:

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Skin and Scuba Diving Questions

1. Do you dive for pleasure? [] Yes [] No Commercial purposes? [] Yes [] No
[] Snorkel [] Scuba
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2. Indicate type of diving (if applicable) [] Instruction [] Construction
[] Salvage [] Search work [] Ice diving [] Night diving
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3. Where do you dive? [] Inland Waters [] Sea or Ocean
[] Other (give details):

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4. Diving History: 5. Do you dive alone?
(in feet) Last 12 months Next 12 months [] Yes [] No
---------------------------------- If "Yes" give details:
No. of Average No. of Average
Dives Time Dives Time --------------------------
----------------------------------------------- 6. (a) Are you a certified
Less than 50 diver?
----------------------------------------------- [] Yes [] No
50-75
----------------------------------------------- (b) Are you a member of
75-100 an organized club?
----------------------------------------------- [] Yes [] No
100 & over If "Yes" give
----------------------------------------------- details:

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7. Have you ever had an accident related to diving? [] Yes [] No
If "Yes" give details:

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Mountain Climbing Questions

1. How long have you been mountain climbing?

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2. At what level do you currently climb?

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3. How often do you climb?

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4. During which seasons?

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5. Give locations including names of mountains and their corresponding level of
difficulty:

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6. What attempts do you have planned in the future?

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I HAVE READ THE ABOVE STATEMENTS AND ANSWERS AND THEY ARE COMPLETE AND TRUE TO
THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THEY WILL FORM A PART OF THE
APPLICATION TO THE COMPANY FOR INSURANCE ON MY LIFE.

Signed at ________________________ this _____ day of ______________________ ____
City/State Month Year

(X) (X)
- -------------------------------------- --------------------------------------
WITNESS SIGNATURE OF PROPOSED LIFE INSURED

(X) (X)
- -------------------------------------- --------------------------------------
WITNESS SIGNATURE OF OWNER, IF OTHER THAN
PROPOSED LIFE INSURED

(X) (X)
- -------------------------------------- --------------------------------------
WITNESS SIGNATURE OF PARENT OR GUARDIAN,
IF MINOR CHILD IS PROPOSED LIFE
INSURED