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Exhibit (A)(10)(b)
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MANULIFE FINANCIAL
THE MANUFACTURERS LIFE INSURANCE
COMPANY OF NEW YORK
Application Supplement for Investment Allocation
and Investor Suitability
THE MANUFACTURERS LIFE INSURANCE COMPANY OF NEW YORK
(hereinafter referred to as The Company)
REQUIRED WITH ALL APPLICATIONS FOR FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE.
PLEASE PRINT AND USE BLACK INK. ANY CHANGES MUST BE INITIALLED BY THE OWNER. A
SIGNATURE IS REQUIRED ON THE REVERSE SIDE.
THIS FORM IS TO BE USED AT THE TIME OF INITIAL APPLICATION ONLY. PLEASE USE
INVESTMENT OPTION CHANGES FORM (IM5085CF) FOR CHANGES AFTER THE POLICY HAS BEEN
ISSUED.
This Application Supplement is deemed to be part of Application No. ____________
Policy No.: ____________ Name of Proposed Life Insured _________________________
(Same as shown on the Application for Flexible Premium Variable Life Insurance)
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INVESTMENT ALLOCATION OF NEW PREMIUMS
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Choose one or more of the accounts listed below by indicating percentages of
net premium. There are no minimum percentages, but allocation percentages must
be whole numbers. TOTAL MUST BE 100%.
VARIABLE ACCOUNTS
AGGRESSIVE GROWTH PORTFOLIOS BALANCED PORTFOLIOS
/ / Pacific Rim Emerging Markets Trust ________% / / Balanced Trust ________%
/ / Science & Technology Trust ________% Automatic Asset Allocation Trusts:
/ / International Small Cap Trust ________% / / Aggressive ________%
/ / Emerging Growth Trust ________% / / Moderate ________%
/ / Pilgrim Baxter Growth Trust ________% / / Conservative ________%
/ / Small/Mid Cap Trust ________%
/ / International Stock Trust ________% BOND PORTFOLIOS:
/ / High Yield Trust ________%
GROWTH PORTFOLIOS: / / Strategic Bond Trust ________%
/ / Worldwide Growth Trust ________% / / Global Government Bond Trust ________%
/ / Global Equity Trust ________% / / Capital Growth Bond Trust ________%
/ / Small Company Value Trust ________% / / Investment Quality Bond Trust ________%
/ / Equity Trust ________% / / U.S. Government Securities Trust ________%
/ / Growth Trust ________%
/ / Quantitative Equity Trust ________% MONEY MARKET PORTFOLIO:
/ / Equity Index Trust ________% / / Money Market Trust ________%
/ / Blue Chip Growth Trust ________%
/ / Real Estate Securities Trust ________% LIFESTYLE PORTFOLIOS:
/ / Lifestyle Aggressive 1000 Trust ________%
GROWTH & INCOME PORTFOLIOS: / / Lifestyle Growth 820 Trust ________%
/ / Value Trust ________% / / Lifestyle Balanced 640 Trust ________%
/ / International Growth and Income Trust ________% / / Lifestyle Moderate 460 Trust ________%
/ / Growth and Income Trust ________% / / Lifestyle Conservative 280 Trust ________%
/ / Equity-Income Trust ________%
GUARANTEED ACCOUNT
/ / Guaranteed Interest Account _________%
NOTE: The maximum amount that may be transferred from the Guaranteed Interest Account (GIA) in any one
policy year is the greater of $500 or 15% of the GIA value at the previous policy anniversary.
(See Over)
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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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INVESTOR SUITABILITY
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THESE QUESTIONS APPLY TO THE OWNER OF THE POLICY. ALL QUESTIONS MUST BE ANSWERED. Yes No
1. Have you received a current prospectus for the policy applied for? ............. / / / /
Date of prospectus __________________ Date of supplement _______________________
2. DO YOU UNDERSTAND THAT UNDER THE POLICY APPLIED FOR:
(a) THE AMOUNT OF THE INSURANCE BENEFITS, OR THE DURATION OF THE INSURANCE
COVERAGE, OR BOTH, MAY BE VARIABLE OR FIXED?................................. / / / /
(b) THE AMOUNT OF THE INSURANCE BENEFITS, THE DURATION OF THE INSURANCE COVERAGE,
AND YOUR POLICY VALUE, MAY INCREASE OR DECREASE DEPENDING ON THE INVESTMENT
EXPERIENCE OF THE CHOSEN INVESTMENT ACCOUNTS AND ARE NOT GUARANTEED AS TO
DOLLAR AMOUNT? .............................................................. / / / /
3. With that in mind, is the policy in accord with your insurance objectives and
your anticipated financial needs? ............................................... / / / /
4. PURPOSE OF INSURANCE
PERSONAL: / / Estate creation / / Estate conservation
BUSINESS: / / Buy-sell / / Deferred compensation / / Keyman / / Pension trust
/ / Other: ____________________________________________________________________________
___________________________________________________________________________________
5. ANNUAL INCOME OF OWNER
/ / $ 250,000 plus / / $ 35,000 to $ 49,999 / / $ 15,000 to $ 19,999
/ / $ 100,000 to $ 249,999 / / $ 25,000 to $ 34,999 / / $ 10,000 to $ 14,999
/ / $ 50,000 to $ 99,999 / / $ 20,000 to $ 24,999 / / Under $10,000
6. NET WORTH OF OWNER
/ / $ 1,000,000 plus / / $ 100,000 to $ 249,999
/ / $ 500,000 to $ 999,999 / / Under $100,000
/ / $ 250,000 to $ 499,999
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SIGNATURES
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Signed at __________________________________________ this _______ day of _______________ ________________
City/State Month Year
(X) (X)
____________________________________________________ ______________________________________________________
WITNESS (REGISTERED REPRESENTATIVE) SIGNATURE OF OWNER
(X) (X)
____________________________________________________ ______________________________________________________
NAME OF REGISTERED REPRESENTATIVE (PRINT NAME) ALL REGISTERED REPRESENTATIVES SHARING COMMISSIONS
MUST SIGN THIS FORM.
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TELEPHONE TRANSFER/ALLOCATION CHANGE AUTHORIZATION
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I UNDERSTAND AND AGREE THAT: Telephone transfers and allocation changes will be
subject to the conditions of the policy, the administrative requirements, The
Company, and the provisions of the policy's prospectus.
The Company, its agents, representatives or employees who act on its behalf
will not be subject to any claim, liability, loss, expense or cost if it acted
upon telephone instructions it reasonably believes to be genuine in reliance on
this signed authorization. The Company will employ reasonable procedures to
confirm the instructions communicated by telephone are genuine. Such procedures
shall consist of confirming a valid telephone authorization form is on file,
tape recording conversations, and providing written confirmation thereof.
The Company, at its option alone and without prior or subsequent notice to the
Owner, or any other person or representative of the Owner, may record all or
part of any telephone conversation containing telephone transfer and/or
allocation change instructions.
All terms of authorization are binding upon the agents, heirs and assignees of
the Owner.
This Telephone Transfer/Allocation Change Authorization will be effective until
such time as: (a) written revocation is received by the Company's Service
Office, or (b) The Company discontinues this privilege, whichever occurs first.
PLEASE CHECK (X) ONLY ONE BOX:
/ / I authorize The Company to accept telephone instructions from me or any
co-owner.
/ / I authorize The Company to accept telephone instructions from me, any
co-owner, or our registered representative. (Registered Representatives
should contact their broker/dealer for procedures regarding this
authorization).
(X) (X)
____________________________________________________ ______________________________________________________
DATE (MMM/DD/YYYY) SIGNATURE OF OWNER(S)
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