[LOGO]
This application for Life Insurance is to John Hancock Variable Life
Insurance Company, which will sometimes hereinafter be referred to as
"the Company."
This application is part of the case applied for in Master Application Number
_________ (if applicable)
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M PROPRIETARY PRODUCTS
[LOGO]
All references to "Life 2" are applicable for Survivorship applications only
Part A Statements to the Company's Agent
A. PROPOSED INSURED / LIFE 1
1. Name of Proposed Insured (please print): 10. Address ________________________________________________
STREET ADDRESS
First _______________________________________ MI ________ _________________________________________________________
CITY STATE ZIP
Last ____________________________________________________ 11. Home Phone (__ __ __) __ __ __ - __ __ __ __
2. Sex [_] Male [_] Female 12. Work Phone (__ __ __) __ __ __ - __ __ __ __
3. Date of Birth _____ / ____ / ____ Fax Number (__ __ __) __ __ __ - __ __ __ __
4. Place of Birth __________________________________________ 13. Best time and place for Underwriting to call (in
STATE COUNTRY, IF NOT U.S.A. Proposed Insured's local time zone) ______________
5. Soc. Sec. Number __ __ __ - __ __ - __ __ __ __
14. Has the Proposed Insured smoked or used any other
6. Height _____ ft. ______ in. 7. Weight ______ lbs. tobacco product, i.e., cigars, pipes, snuff, chewing
tobacco, etc., in the past 12 months?
8. Occupation ______________________________________________
[_] Yes [_] No
9. Driver's License State____Number_____________
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B. SECOND PROPOSED INSURED / LIFE 2 (COMPLETE ONLY IF SURVIVORSHIP)
1. Name of Proposed Insured (please print): 11. Address ____________________________________________
STREET ADDRESS
First _______________________________________ MI ________ ____________________________________________________
CITY STATE ZIP
Last ____________________________________________________ 12. Home Phone (__ __ __) __ __ __ - __ __ __ __
2. Sex [_] Male [_] Female 13. Work Phone (__ __ __) __ __ __ - __ __ __ __
3. Date of Birth _____ / ____ / ____ Fax Number (__ __ __) __ __ __ - __ __ __ __
4. Place of Birth __________________________________________ 14. Best time and place for Underwriting to call (in
STATE COUNTRY, IF NOT U.S.A. Proposed Insured's local time zone) ______________
5. Soc. Sec. Number __ __ __ - __ __ - __ __ __ __ 15. Has the Proposed Insured smoked or used any other
tobacco product, i.e., cigars, pipes, snuff, chewing tobacco,
6. Height _____ ft. ______ in. 7. Weight ______ lbs. etc., in the past 12 months?
8. Occupation ______________________________________________ [_] Yes [_] No
9. Driver's License State____Number_____________
10. What is Life 2's relationship to Life 1? _________________
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Page 1
Part A Statements to the Company's Agent
C. OWNER
1. Policy Owner Complete questions 3-5 if Owner is a Trust
[_] Trust 3. Name of Trust _________________________________________
[_] Life 1 [_] Life 2 [_] Life 1 and Life 2, jointly ____________________________________________________________
(Choices that include Life 2 are only for survivorship ____________________________________________________________
applications)
[_] 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 POLICY IS TO BE OWNED BY A TRUST
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6. Other Owners, if any
NAME OF RELATIONSHIP SOC. SEC. DATE OF BIRTH
OWNERS TO LIFE 1 AND LIFE 2 NUMBER
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
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7. Name/Address/Phone for mailing of policy statements and 8. Name/Address/Phone for mailing of
correspondence other than premium notices: 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
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D. UNDERWRITING INFORMATION
1. In the past 7 years, has the Proposed Insured(s) done, or does the Life 1 Life 2
Proposed Insured(s) intend to do any: (if survivorship)
a. flying except as a passenger on regularly scheduled airlines? [_] Yes [_] No [_] Yes [_] No
(If yes, please complete aviation questionnaire.)
b. skin/scuba diving, parachuting, motorized racing, or other hazardous
sports? (If yes, please complete avocation questionnaire.) [_] Yes [_] No [_] Yes [_] No
2. In the past 7 years, has the Proposed Insured(s) been convicted of two or
more motor vehicle moving violations or had a driving license suspended or
revoked? [_] Yes [_] No [_] Yes [_] No
3. In the past 7 years, has the Proposed Insured(s) been convicted of the
violation of any criminal law, or are any criminal charges now pending
against the Proposed Insured(s)? [_] Yes [_] No [_] Yes [_] No
4. Does the Proposed Insured(s) intend to reside or travel outside the U.S. or
Canada? [_] Yes [_] No [_] Yes [_] No
If any of questions 2 - 4 are answered "yes", please explain:
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
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Page 2
Part A Statements to the Company's Agent
E. OTHER INSURANCE/REPLACEMENT INFORMATION
1. Give information indicated for all insurance in force on the Proposed Insured(s), including term riders.
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Life 1/2 Company Issue Year Plan Amount ADB Amount Business Insurance?
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[_] Yes [_] No
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[_] Yes [_] No
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[_] Yes [_] No
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[_] Yes [_] No
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[_] Yes [_] No
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2. Is any other insurance application now pending or contemplated on the life of [_] Yes [_] No
the Proposed Insured(s)? (Include any Life, Disability, or Long Term Care)
If yes, which Insured(s) _________________________________________________________________________________________________
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 Insured(s)? (If yes, give writing company of insurance
being replaced, policy number, and insurance amount.)
Life 1 Life 2 (if survivorship)
--------------------------------------------------------------------------------------------------------------------------
Company Policy # Amount Company Policy # Amount
--------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------
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4. Has any application for life, disability, or health insurance on the Proposed Insured(s) Life 1 [_] Yes [_] No
ever been modified? (If "Yes," give most recent company, Life 2 [_] Yes [_] No
including John Hancock.) ______________________________________________________________________________________________________
COMPANY APPROXIMATE DATE
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F. SPECIAL REQUESTS
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G. BENEFICIARY
Please indicate full name and relationship to the Proposed Insured(s). (please print)
The right to change the beneficiary as to any proceeds is reserved to the Owner(s).
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Notice:
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
false or deceptive statement may be guilty of insurance fraud.
Page 3
Part A Statements to the Company's Agent
PLEASE COMPLETE THIS PAGE IF MAJESTIC VARIABLE COLI IS DESIRED
H. BENEFITS I. PREMIUM
1. Basic Sum Insured (BSI) $__________________ 1. Premium Billing interval
2. Death Benefit Option (choose one) [_] Annual [_] Semiannual
[_] Option A - Sum Insured only [_] Quarterly [_] Monthly-(Automatic Deduction)
[_] Option B - Sum Insured plus Account Value
3. Life Insurance Definition (choose one) 2. Planned Premium (Check a or b, or Target Premium will be billed.)
[_] Cash Value Accumulation Test
[_] Guideline Premium Test a. [_] $____________ annually for______year(s)
Optional: Annual Increase of _____% OR
4. Additional Sum Insured (ASI) (check if desired) $___________ annually for ____ year(s)
a. (Check no more than one of the following)
[_] ASI of $_____________ Additional first year Planned Premium $_______
[_] for life of policy.
[_] with Total Sum Insured $______increasing
by [_] ___% or [_] $_______ per year for b. [_] Customized Schedule (list by policy year or years):
[_] life of policy or [_] _______ policy
years.
[_] Customized Level or Increasing Schedule Policy Year(s) Planned Premium Amount
(list by policy year or years, ASI amount -------------- ----------------------
may not decrease) _____-_____ $______________ (1)
Policy Year(s) ASI Amount _____-_____ $______________ (2)
-------------- ---------- _____-_____ $______________ (3)
_____-_____ $_____________ (1) _____-_____ $______________ (4)
_____-_____ $_____________ (2) _____-_____ $______________ (5)
_____-_____ $_____________ (3) _____-_____ $______________ (6)
_____-_____ $_____________ (4) _____-_____ $______________ (7)
_____-_____ $_____________ (5) _____-_____ $______________ (8)
_____-_____ $_____________ (6) _____-_____ $______________ (9)
_____-_____ $_____________ (7) _____-_____ $______________ (10)
_____-_____ $_____________ (8) (If more space needed, attach separate schedule)
_____-_____ $_____________ (9)
_____-_____ $_____________ (10)
(If more space needed, attach separate schedule)
b. [_] Premium Cost Recovery
[_] life of policy or [_] _____ policy years
5 Additional Benefits
[_] Continuation of Guaranteed Minimum Death
Benefit Option after 10th Policy Year
(not available with Option B)
[_] Enhanced Cash Value Rider
[_] Other ___________________________________
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J. VARIABLE PRODUCTS INFORMATION
IF ELECTING MAJESTIC VARIABLE COLI, COMPLETE SECTIONS K, L, & M ON PAGE 4A OF
THIS APPLICATION.
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Page 4 (Majestic Variable COLI)
Part A Statements to the Company's Agent
PLEASE COMPLETE THIS PAGE IF VARIABLE MASTERPLAN PLUS IS DESIRED
H. BENEFITS I. PREMIUM
1. Basic Sum Insured (BSI) $__________________ 1. Premium Billing interval
2. Death Benefit Option (choose one) [_] Annual [_] Semiannual
[_] Option A - Sum Insured only [_] Quarterly [_] Monthly-(Automatic Deduction)
[_] Option B - Sum Insured plus Account Value
3. Life Insurance Definition (choose one) 2. Planned Premium (Check a or b, or Target Premium will be billed.)
[_] Cash Value Accumulation Test
[_] Guideline Premium Test a. [_] $____________ annually for______year(s)
Optional: Annual Increase of _____% OR
4. Additional Sum Insured (ASI) (check if desired) $___________ annually for ____ year(s)
a. (Check no more than one of the following)
[_] ASI of $_____________ Additional first year Planned Premium $_______
[_] for life of policy.
[_] with Total Sum Insured $______increasing
by [_] ___% or [_] $_______ per year for b. [_] Customized Schedule (list by policy year or years):
[_] life of policy or [_] _______ policy
years.
[_] Customized Level or Increasing Schedule Policy Year(s) Planned Premium Amount
(list by policy year or years, ASI amount -------------- ----------------------
may not decrease) _____-_____ $______________ (1)
Policy Year(s) ASI Amount _____-_____ $______________ (2)
-------------- ---------- _____-_____ $______________ (3)
_____-_____ $_____________ (1) _____-_____ $______________ (4)
_____-_____ $_____________ (2) _____-_____ $______________ (5)
_____-_____ $_____________ (3) _____-_____ $______________ (6)
_____-_____ $_____________ (4) _____-_____ $______________ (7)
_____-_____ $_____________ (5) _____-_____ $______________ (8)
_____-_____ $_____________ (6) _____-_____ $______________ (9)
_____-_____ $_____________ (7) _____-_____ $______________ (10)
_____-_____ $_____________ (8) (If more space needed, attach separate schedule)
_____-_____ $_____________ (9)
_____-_____ $_____________ (10)
(If more space needed, attach separate schedule)
b. [_] Premium Cost Recovery
[_] life of policy or [_] _____ policy years
5 Additional Benefits
[_] Continuation of Guaranteed Minimum Death
Benefit Option after 10th Policy Year
(not available with Option B)
[_] Enhanced Cash Value Rider
[_] Other ___________________________________
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J. VARIABLE PRODUCTS INFORMATION
IF ELECTING VARIABLE MASTERPLAN PLUS, COMPLETE SECTIONS K, L, & M ON PAGE 4A OF
THIS APPLICATION.
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Page 4 (Variable MasterPlan Plus)
Part A Statements to the Company's Agent
PLEASE COMPLETE THIS PAGE IF MAJESTIC UL - COLI IS DESIRED
H. BENEFITS I. PREMIUM
1. Basic Sum Insured (BSI) $__________________ 1. Premium Billing Interval
2. Death Benefit Option (choose one) [_] Annual [_] Semiannual
[_] Option A - Sum Insured only [_] Quarterly [_] Monthly-(Automatic Deduction)
[_] Option B - Sum Insured plus Account Value
3. Life Insurance Definition (choose one) 2. Planned Premium (Check a or b, or Target Premium will be billed.)
[_] Cash Value Accumulation Test
[_] Guideline Premium Test a. [_] $____________ annually for______year(s)
Optional: Annual Increase of _____% OR
4. Additional Sum Insured (ASI) (check if desired) $___________ annually for ____ year(s)
a. (Check no more than one of the following)
[_] ASI of $_____________ Additional first year Planned Premium $_______
[_] for life of policy.
[_] with Total Sum Insured $______increasing
by [_] ___% or [_] $_______ per year for b. [_] Customized Schedule (list by policy year or years):
[_] life of policy or [_] _______ policy
years.
[_] Customized Level or Increasing Schedule Policy Year(s) Planned Premium Amount
(list by policy year or years, ASI amount -------------- ----------------------
may not decrease) _____-_____ $______________ (1)
Policy Year(s) ASI Amount _____-_____ $______________ (2)
-------------- ---------- _____-_____ $______________ (3)
_____-_____ $_____________ (1) _____-_____ $______________ (4)
_____-_____ $_____________ (2) _____-_____ $______________ (5)
_____-_____ $_____________ (3) _____-_____ $______________ (6)
_____-_____ $_____________ (4) _____-_____ $______________ (7)
_____-_____ $_____________ (5) _____-_____ $______________ (8)
_____-_____ $_____________ (6) _____-_____ $______________ (9)
_____-_____ $_____________ (7) _____-_____ $______________ (10)
_____-_____ $_____________ (8) (If more space needed, attach separate schedule)
_____-_____ $_____________ (9)
_____-_____ $_____________ (10) 3. Do you understand that you may need to pay
(If more space needed, attach separate schedule) additional premiums should the current credited
rates or charges change from those in your
b. [_] Premium Cost Recovery illustration? [_] Yes [_] No
[_] life of policy or [_] _____ policy years
5 Additional Benefits
[_] Enhanced Cash Value Rider
[_] Other ___________________________________
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Page 4 (Majestic UL-COLI)
Part A Statements to the Company's Agent
PLEASE COMPLETE THIS PAGE IF MAJESTIC UL-SURVIVORSHIP 98 IS DESIRED
H. BENEFITS I. PREMIUM
1. Basic Sum Insured (BSI) $_____________________ 1. Premium Billing Interval
2. Death Benefit Option (choose one) [_] Annual [_] Semiannual
[_] Quarterly [_] Monthly-(Automatic Deduction)
[_] Option A - Sum Insured only
[_] Option B - Sum Insured plus Account Value
[_] Option M - Sum Insured plus Optional Extra Death
Benefit with calculation beginning at policy year ___ 2. Planned Premium (Check a or b, or Target Premium will be
billed.)
3. Life Insurance Definition (choose one)
a. [_] $____________ annually for______year(s)
[_] Cash Value Accumulation Test Optional: Annual Increase of _____% OR
[_] Guideline Premium Test (Option M not allowed) $___________ annually for ____ year(s)
4. Additional Sum Insured (ASI) (check if desired)
a. (Check no more than one of the following) Additional first year Planned Premium $_______
[_] ASI of $________________
[_] for life of policy.
[_] with Total Sum Insured increasing by b. [_] Customized Schedule (list by policy year or years):
[_] ____% or [_] $__________per year for
[_] life of policy or [_] ______ policy years. Policy Year(s) Planned Premium Amount
-------------- ----------------------
[_] Customized Level or Increasing Schedule ______-______ $_____________ (1)
(list by policy year or years, ASI amount may not decrease) ______-______ $_____________ (2)
______-______ $_____________ (3)
Policy Year(s) ASI Amount ______-______ $_____________ (4)
-------------- ---------- ______-______ $_____________ (5)
______-______ $_____________ (1) ______-______ $_____________ (6)
______-______ $_____________ (2) ______-______ $_____________ (7)
______-______ $_____________ (3) ______-______ $_____________ (8)
______-______ $_____________ (4) ______-______ $_____________ (9)
______-______ $_____________ (5) ______-______ $_____________ (10)
______-______ $_____________ (6) (If more space needed, attach separate schedule)
______-______ $_____________ (7)
______-______ $_____________ (8)
______-______ $_____________ (9)
______-______ $_____________ (10) 3. Do you understand that you may need to pay
(If more space needed, attach separate schedule) additional premiums should the current credited
rates or charges change from those in your
b. [_] Premium Cost Recovery illustration? [_] Yes [_] No
[_] life of policy or [_] ______ policy years
5. Additional Benefits
[_] Policy Split Option
[_] Enhanced Cash Value Rider
[_] Other ______________________________________________
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Page 4 (Majestic UL-Survivorship 98)
PLEASE COMPLETE THIS PAGE IF MAJESTIC VUL 98 IS DESIRED
H. BENEFITS I. PREMIUM
1. Basic Sum Insured (BSI) $_____________________ 1. Premium Billing Interval
2. Death Benefit Option (choose one) [_] Annual [_] Quarterly
[_] Semiannual [_] Monthly-(Automatic Deduction)
[_] Option A - Sum Insured only
[_] Option B - Sum Insured plus Account Value
[_] Option M - Sum Insured plus Optional Extra Death
Benefit with calculation beginning at policy year ___ 2. Planned Premium (Check a or b, or Target Premium will be
billed.)
3. Life Insurance Definition (choose one)
a. [_] $____________ annually for______year(s)
[_] Cash Value Accumulation Test Optional: Annual Increase of _____% OR
[_] Guideline Premium Test (Option M not allowed) $___________ annually for ____ year(s)
4. [_] Additional Sum Insured (ASI) (check if desired)
a. (Check no more than one of the following) Additional first year Planned Premium $_______
[_] ASI of $________________
[_] for life of policy.
[_] with Total Sum Insured increasing by b. [_] Customized Schedule (list by policy year or years):
[_] ____% or [_] $__________per year for
[_] life of policy or for [_] ______ Policy Years. Policy Year(s) Planned Premium Amount
-------------- ----------------------
[_] Customized Level or Increasing Schedule ______-______ $_____________ (1)
(list by policy year or years, ASI amount may not decrease) ______-______ $_____________ (2)
______-______ $_____________ (3)
Policy Year(s) ASI Amount ______-______ $_____________ (4)
-------------- ---------- ______-______ $_____________ (5)
______-______ $_____________ (1) ______-______ $_____________ (6)
______-______ $_____________ (2) ______-______ $_____________ (7)
______-______ $_____________ (3) ______-______ $_____________ (8)
______-______ $_____________ (4) ______-______ $_____________ (9)
______-______ $_____________ (5) ______-______ $_____________ (10)
______-______ $_____________ (6) (If more space needed, attach separate schedule)
______-______ $_____________ (7)
______-______ $_____________ (8)
______-______ $_____________ (9)
______-______ $_____________ (10)
(If more space needed, attach separate schedule)
b. [_] Premium Cost Recovery
[_] life of policy or [_] ______ policy years
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5. Additional Benefits J. VARIABLE PRODUCTS INFORMATION
[_] Continuation of Guaranteed Minimum Death
Benefit Option after 10th Policy Year
(not available with Option B) IF ELECTING MAJESTIC VUL 98
[_] Living Care Benefit (Accelerated Death Benefit)
COMPLETE SECTIONS K, L, & M ON PAGE
[_] Enhanced Cash Value Rider 4A OF THIS APPLICATION.
[_] Other ______________________________________________
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Page 4 (Majestic VUL 98)
Part A Statements to the Company's Agent
PLEASE COMPLETE THIS PAGE IF MAJESTIC VEP 98 IS DESIRED
H. BENEFITS I. PREMIUM
1. Basic Sum Insured (BSI) $_____________________ 1. Premium Billing Interval
2. Death Benefit Option (choose one) [_] Annual [_] Quarterly
[_] Semiannual [_] Monthly-(Automatic Deduction)
[_] Option A - Sum Insured only
[_] Option B - Sum Insured plus Account Value
[_] Option M - Sum Insured plus Optional Extra Death
Benefit with calculation beginning at policy year ___ 2. Planned Premium (Check a or b, or Target Premium will be
billed.)
3. Life Insurance Definition (choose one)
a. [_] $____________ annually for______year(s)
[_] Cash Value Accumulation Test Optional: Annual Increase of _____% OR
[_] Guideline Premium Test (Option M not allowed) $___________ annually for ____ year(s)
4. [_] Additional Sum Insured (ASI) (check if desired)
a. (Check no more than one of the following) Additional first year Planned Premium $_______
[_] ASI of $________________
[_] for life of policy.
[_] with Total Sum Insured increasing by b. [_] Customized Schedule (list by policy year or years):
[_] ____% or [_] $__________per year for
[_] life of policy or [_] ______ Policy Years. Policy Year(s) Planned Premium Amount
-------------- ----------------------
[_] Customized Level or Increasing Schedule ______-______ $_____________ (1)
(list by policy year or years, ASI amount may not decrease) ______-______ $_____________ (2)
______-______ $_____________ (3)
Policy Year(s) ASI Amount ______-______ $_____________ (4)
-------------- ---------- ______-______ $_____________ (5)
______-______ $_____________ (1) ______-______ $_____________ (6)
______-______ $_____________ (2) ______-______ $_____________ (7)
______-______ $_____________ (3) ______-______ $_____________ (8)
______-______ $_____________ (4) ______-______ $_____________ (9)
______-______ $_____________ (5) ______-______ $_____________ (10)
______-______ $_____________ (6) (If more space needed, attach separate schedule)
______-______ $_____________ (7)
______-______ $_____________ (8)
______-______ $_____________ (9)
______-______ $_____________ (10)
(If more space needed, attach separate schedule)
b. [_] Premium Cost Recovery
[_] life of policy or [_] ______ policy years
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5. Additional Benefits J. VARIABLE PRODUCTS INFORMATION
[_] Continuation of Guaranteed Minimum Death
Benefit Option after 10th Policy Year
(not available with Option B) IF ELECTING MAJESTIC VEP 98
[_] Policy Split Option
COMPLETE SECTIONS K, L, & M ON PAGE
[_] Enhanced Cash Value Rider 4A OF THIS APPLICATION.
[_] Other ______________________________________________
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Page 4 (Majestic VEP 98)
Part A Statements to the Company's Agent
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PLEASE COMPLETE THIS PAGE IF MAJESTIC UL IS DESIRED
H. BENEFITS I. PREMIUM
1. Basic Sum Insured (BSI)$_____________________ 1. Premium Billing Interval
2. Death Benefit Option (choose one) [_] Annual [_] Semiannual
[_] Quarterly [_] Monthly-(Automatic Deduction)
[_] Option A - Sum Insured only
[_] Option B - Sum Insured plus Account Value
[_] Option M - Sum Insured plus Optional Extra Death
Benefit with calculation beginning at policy year___ 2. Planned Premium (Check a or b, or Target Premium will be
billed.)
3. Life Insurance Definition (choose one)
[_] Cash Value Accumulation Test a. [_] $____________ annually for______year(s)
[_] Guideline Premium Test (Option M not allowed) Optional: Annual Increase of _____% OR
$___________ annually for ____ year(s)
4. [_] Additional Sum Insured (ASI) (check if desired)
Additional first year Planned Premium $_______
a. (Check no more than one of the following)
[_] ASI of $________________
[_] for life of policy. b. [_] Customized Schedule (list by policy year or years):
[_] with Total Insured increasing by
[_] ____% or $__________per year for Policy Year(s) Planned Premium Amount
[_]life of policy or ______policy years. -------------- ----------------------
_____-________ $______________ (1)
_____-________ $______________ (2)
[_] Customized Level or Increasing Schedule _____-________ $______________ (3)
(list by policy year or years, ASI amount may not decrease) _____-________ $______________ (4)
_____-________ $______________ (5)
Policy Year(s) ASI Amount _____-________ $______________ (6)
-------------- ---------- _____-________ $______________ (7)
_______-______ $_____________ (1) _____-________ $______________ (8)
_______-______ $_____________ (2) _____-________ $______________ (9)
_______-______ $_____________ (3) _____-________ $______________ (10)
_______-______ $_____________ (4) (If more space needed, attach separate schedule)
_______-______ $_____________ (5)
_______-______ $_____________ (6) 3. Do you understand that you may need to pay
_______-______ $_____________ (7) additional premiums should the current credited
_______-______ $_____________ (8) rates or charges change from those in your
_______-______ $_____________ (9) illustration? Yes [_] No [_]
_______-______ $_____________ (10)
(If more space needed, attach separate schedule)
b. [_] Premium Cost Recovery
[_] life of policy or [_]_____ policy years
5. Additional Benefits
[_] Living Care Benefit (Accelerated Death Benefit)
[_] Enhanced Cash Value Rider
[_] Other __________________________________
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Page 4 (Majestic UL)
THIS PAGE MUST BE COMPLETED FOR ALL VARIABLE PRODUCTS
K. PLAN
Choose One:
[_] Majestic Variable COLI [_] Variable Master Plan Plus [_] Majestic VUL 98
[_] Majestic VEP 98 [_] Other _____________
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L. SUBACCOUNT INVESTMENT OPTIONS
What investment style are you hoping to meet with your sub-account investment option? Check if Dollar Cost Averaging.
[_] Conservative [_] Moderately Aggressive [_] Moderately Conservative [_] Aggressive
Percentages must be Whole and Total 100%
Domestic Equities Bond, Money Market, & Fixed M Proprietary
___% Growth & Income ___% Money Market ___% Edinburgh Overseas Equity
___% Equity Index ___% Sovereign Bond ___% Turner Core Growth
___% Large Cap Growth ___% Fixed Account ___% Frontier Capital Appreciation
___% Large Cap Value ___% Short-Term Bond ___% Enhanced U.S. Equity Fund
___% Real Estate Equity ___% Strategic Bond
___% Diversified Mid Cap Growth
___% Mid Cap Growth
___% Mid Cap Value Other (if available) International
___% Small Cap Growth ___% _______________ ___% International Equity Index
___% Small Cap Value ___% _______________ ___% International Opportunities
___% Managed ___% International Balanced
Are you associated with another NASD Member Firm? [_] No [_] Yes Specify____________________________________
Telephone Transfer Option (Phonetran)
I 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, transfer existing funds among the
subaccount investment options, and process policy loans, subject to the provisions of the Contract.
Telephone Subaccount Transfer [_] Yes [_] No
Telephone Loan [_] Yes [_] No
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Page 4A (Subaccount Investment Options)
THIS PAGE IS INTENTIONALLY LEFT BLANK.
NOTICE OF POTENTIAL INCOME TAX IMPLICATIONS FOR 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 policy, you will be affected by this law.
It is important for you to understand that all distributions made from your
policy as applied for, including policy loans, withdrawals, partial surrenders
and certain dividends (if applicable), will be considered to be a distribution
of any gain. This means that if your policy is in a gain position when the
withdrawal is made (i.e., the value of your policy 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 Insured(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 upon 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 Acknowledgment below.
Policyowner Acknowledgment and Signature
I have read the above Notice of Potential Income Tax Implications. I
understand that my premium payments will cause the proposed policy to become a
Modified Endowment. I also understand the potential income tax effects of a
distribution from a Modified Endowment.
Policyowner Signature _____________________________ Date __________________
- --------------------------------------------------------------------------------
TAXPAYER IDENTIFICATION NUMBER
Enter the Owner's taxpayer identification number in the
appropriate box. For most individual taxpayers, this is the
social security number.
-------------------------------------------
Social Security number
___ ___
-------------------------------------------
OR
-------------------------------------------
Employer identification number
___
-------------------------------------------
I submit that the information provided above is true, correct, and complete.
Signature___________________________________ Date_______________
- --------------------------------------------------------------------------------
Page 5
Part B Statements to the Company's Agent
COMPLETE FOR NON-MEDICAL APPLICATIONS ONLY
Please give full details below for every "Yes" answer to Questions 1 - 4 as to each person proposed for insurance, who is
referred to below as "any person." Be sure to include the names/addresses of any treatment providers.
1. Within the past 7 years, has any person 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 any person had or been diagnosed or treated by
a physician or othr medical practitioner for Human Immunodeficiency Virus or
Aquired Immune Deficiency Syndrome (AIDS)? [_] Yes [_] No
3. Within the past 7 years, has any person 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 any person
a) been admitted to a hospital or other medical or rehabilitation facility? [_] Yes [_] No
b) consulted or been treated by a physician, or had a physical exam or checkup? [_] Yes [_] No
5. Is any person currently taking any prescription drug? [_] Yes [_] No
If yes, who? What drugs? How frequently? ___________________________________________________________________________________
- ------------------------------------------------------------------------------------------------------------------------------------
6. If the Proposed Insured(s) has a personal physician, please enter name, address, and details below. Otherwise leave blank.
Life 1 Life 2
- ----------------------------------------------------------------- --------------------------------------------------------------
FIRST NAME MI LAST NAME FIRST NAME MI LAST NAME
- ----------------------------------------------------------------- --------------------------------------------------------------
STREET ADDRESS CITY STATE ZIP STREET ADDRESS CITY STATE ZIP
Date/Reason(s) last seen ________________________________________ Date/Reason(s) last seen _____________________________________
- ------------------------------------------------------------------------------------------------------------------------------------
Details to "yes" answers. Question No./Name___________________________________________
Question No./Name____________________________________________ 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./Name____________________________________________ Question No./Name___________________________________________
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 6
Statements to the Company's Agent
AGREEMENT 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 policy 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 requirements of such Conditional Temporary Insurance
Agreement; and (2) the amount applied for in this and all other
applications now pending in John Hancock Variable Life Insurance Company
does not exceed $1,000,000 life insurance if an individual policy or
$3,000,000 life insurance if a survivorship policy.
C. If the applicant has a right to have the new policy issued as requested
without completing any Part B, the new policy 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 policy or
Benefit provision will take effect as of the Date of Issue of the policy,
but: (1) only on delivery to and receipt by the Applicant of the policy and
payment of the minimum initial premium thereon and (2) only if at the time
of such delivery and payment each person proposed for insurance 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,
policy, 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.
Provisions F and G apply only if a Variable Product is applied for
F. All benefits, payments, and values, including the Death Benefit and Account
or Cash Value, under any policy 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
or Cash Value may even decrease to zero.
G. A prospectus for the policy applied for has been given to the Proposed
Insured and/or to the Applicant.
Prospectus Date: ____________
Provisions H, I, J, K, and L apply if the policy applied for is the
result of a term conversion
H. The new policy will be a new, separate contract. If the new policy is
issued in exchange for the original insurance, all liability of the Company
under the original insurance will cease when the new policy takes effect.
Until the new policy is issued, coverage will still be in force under the
original policy. Coverage under the new policy 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 policy.
J. If the original policy or benefit provision is being exchanged and is
subject to an assignment, the new policy will be subject to the same
assignment unless it is discharged or, in the case of a policy loan
assignment, unless the indebtedness has been repaid.
K. If the new policy is issued in exchange for the original policy, any
nonforfeiture option election applicable to the original policy will be
applicable to the new policy, if available, unless otherwise requested in
writing.
L. Ownership and control of any policy issued on the attached application will
be determined by the terms of the new policy.
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 assent to this application.
- --------------------------------------------------------------------------------
_______________________________________________Dated At _________________________________________ on ______________ , ______
APPPLICANT'S SIGNATURE CITY OR TOWN STATE DATE
_______________________________________________Dated At _________________________________________ on ______________ , ______
APPPLICANT'S SIGNATURE CITY OR TOWN STATE DATE
_______________________________________________Dated At _________________________________________ on ______________ , ______
APPPLICANT'S SIGNATURE CITY OR TOWN STATE DATE
___________________________________ ___________________________________ __________________________________
SIGNATURE OF LIFE 1, IF OTHER THAN SIGNATURE OF LIFE 2, IF OTHER THAN WITNESS (Agent must witness where
APPLICANT APPLICANT required by law)
Page 7
VERIFICATION OF TRUST
1. Names of Proposed Insured(s) (please print): 5. Names of Additional Trustees:
________________________________________________ ______________________________________________
FIRST NAME M I LAST NAME FIRST NAME M I LAST NAME
________________________________________________ ______________________________________________
FIRST NAME M I LAST NAME FIRST NAME M I LAST NAME
2. Name of Trust: ______________________________________________
FIRST NAME M I LAST NAME
________________________________________________
______________________________________________
FIRST NAME M I LAST NAME
________________________________________________
________________________________________________ 6. Date of Trust _____ / _____ / _____
3. Name of Trustee:
_______________________________________________ 7. Trust established in state of
FIRST NAME MIDDLE INITIAL LAST NAME
_____________________________
4. Address of Trustee: 8. Taxpayer ID # (when available)
_______________________________________________ __________________________
STREET ADDRESS
_______________________________________________
CITY STATE ZIP 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 Insured(s). 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 policies and the Trustee(s) can exercise these rights
without the consent of the Insured(s). These rights include but are not limited
to: surrendering the policy, withdrawing policy values, borrowing against the
policy values, assigning the policy, transferring ownership, and changing the
beneficiary.
The undersigned Trustee(s) agree(s) that John Hancock Variable Life Insurance
Company shall not be responsible for the application or disposition of the
proceeds of said policy purchased by the Trustee(s), and the payment to the
Trustee(s) of the proceeds of the policy shall fully discharge John Hancock
Variable Life Insurance Company from all liability under said policy 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
judgments against them arising from effecting any insurance transactions in
reliance on this certification.
Dated At____________________________________on________________ , _______
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 NON-COLI CASES
1. Please provide the Proposed Insured'(s) 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. _____________________________________________________
Life 2 (if survivorship)
_______yrs. _______mos. See Part A, Page 1, Section B
-----------------------------------------------------
_______yrs. _______mos. _____________________________________________________
2. Please provide the Proposed Insured'(s) employment details for the last two
years.
Time Employed Employer Name Street Address City/Town State ZIP
_______yrs. ______mos. _____________________________________________________
_______yrs._______mos. _____________________________________________________
Life 2 (if survivorship)
______yrs.______mos. _____________________________________________________
______yrs.______mos. _____________________________________________________
3. How long have you known the Proposed Insured(s)?Life 1?_____________
Life 2?___________ (if survivorship)
4. Are you related to the Proposed Insured(s)? [_] Yes (relationship) __________
[_] No
5. Has the Proposed Insured(s) been known by any Yes [_] (what names)
_______________ [_] No other names within the last ten years?
- --------------------------------------------------------------------------------
From my knowledge and investigation, the proposed insured(s) is ----AGENT-------------------------------------------------
of temperate habits and good moral character, and I know nothing Is the insurance applied for intended [_] Yes [_] No
affecting the insurability of the Proposed Insured(s) not stated to replace or change any life insurance
hereon, and I recommend his/her acceptance without qualification. or annuity now in force on the Proposed Insured(s)?
Proposed Insured(s) interviewed by me on ___/___/___. ----------------------------------------------------------
This application and report have been reviewed by me,
and I recommend the risk.
The Federal Fair Credit Reporting Act notice has been ___________________________________________________________
delivered as required. Producer
- ----------------------------------------------------------------------------------------------------------------------------------
AUTHORIZATION FOR AUTOMATIC DEDUCTION BILLING
I authorize the Company to deduct the monthly premiums for the policy
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 Variable Life. Accept advance payment only if able
to issue Receipt and Conditional TIA.
(1035 external replacements, individual policies with face amounts over
$1,000,000, and survivorship policies with face amounts over $3,000,000 may not
be prepaid)
- --------------------------------------------------------------------------------
III.COMPLETE IF THIS IS A CONVERSION OF TERM INSURANCE
1. [_] This is a [_] Full [_] Partial Term Conversion from:
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------------------------
a. Policy Number/Insured Conversion Type Amount Converted Amount Remaining In Force
- --------------------------------------------------------------------------------------------------
Name Base Policy Amount
------------------ ------------------- -------------------------
--------------------------- -------------Rider
------------------ ------------------- -------------------------
# -------------Rider
- --------------------------------------------------------------------------------------------------
b.Policy Number/Insured Conversion Type Amount Converted Amount Remaining In Force
- --------------------------------------------------------------------------------------------------
Name Base Policy Amount
------------------ ------------------- -------------------------
--------------------------- -------------Rider
------------------ ------------------- -------------------------
# -------------Rider
- --------------------------------------------------------------------------------------------------
2. Is Insured(s) now totally disabled, or is Insured(s) receiving any
payments for sickness or injury? [_] Yes [_] No
(If yes, give details in the Special Requests Box F)
- --------------------------------------------------------------------------------
IV.COMPLETE FOR MODIFIED ENDOWMENTS
1. Does the sales illustration show that the policy applied for is a Modified
Endowment Contract (MEC)? [_] Yes [_] No
2. If yes, has the Policyowner signed the MEC Acknowledgment Form on Page 5?
[_] Yes [_] No
- --------------------------------------------------------------------------------
TO BE COMPLETED IN EVERY CASE
Authorization and Acknowledgment
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 Insured(s)
signature.
____________________________________ ________________________________________
Signature of Life 1 Signature of Life 2 (survivorship only)
_____________________, _______ __________________________, __________
Date Date
-------------------------------------------------------------------------------
Page 10
RECEIPT AND CONDITIONAL TEMPORARY INSURANCE AGREEMENT
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 (individual)
or $1,000,000 (survivorship) on all applications pending on each person
proposed for insurance with John Hancock Variable Life Insurance Company,
regardless of the number of applications, and the face amounts of the
policies applied for.
Life 1_________________________________ Application Number_________________
Life 2 (if survivorship)______________ Total Sum Insured at Issue $ ______
Plan__________________________________ Date_______________________________
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 the company under which
your application is being made (John Hancock Variable Life), at
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 any person proposed for insurance consulted a
physician for, been diagnosed with, or had treatment for heart disease,
stroke, or cancer?_______
b. Has any person proposed for insurance been hospitalized within the past 6
months or been advised by a physician that he or she needs hospitalization
for any reason (other than for normal pregnancy)?_______
c. Within the past 7 years, has any person received counseling or treatment
regarding the use of alcohol, drugs, illegal drugs, or used any illegal
drug or controlled substance?_______
d. Within the past 7 years, has any person had a driving license suspended or
revoked?_______
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 policy applied for will take effect on the latest "Completion
Date" of all persons proposed for insurance. Each person's "Completion Date"
will be the date of completion of the latest of the 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 if
individual life insurance or $1,000,000 if survivorship life insurance. However,
the amount of coverage will never exceed $250,000 (individual) or $1,000,000
(survivorship) less the total of all amounts payable under all conditional
temporary insurance agreements issued by John Hancock Variable Life Insurance
Company in connection with any insurance application pending on the Proposed
Insured(s) as of the date of this Receipt and Conditional Temporary Insurance
Agreement. No benefit will be paid under this Agreement if the Proposed
Insured'(s) death(s) 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)
Fraud Warning. 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 false or deceptive statement may be guilty of insurance fraud.
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 policy issued on the basis of the
application.
2) The date the Applicant refuses to accept the policy as offered for
delivery.
3) The date the application is declined or deemed declined (Policy 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 be in effect under both
this Conditional Temporary Insurance Agreement and any policy 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 Policy. Coverage under any policy issued on
the basis of the application will replace the coverage provided by this
Agreement as of the policy Date of Issue but only if:
1) The policy is delivered to and accepted by the Applicant while all persons
proposed for insurance are living and within 60 days of the latest
"Completion Date," and
2) The balance of any premium required for the policy as delivered is paid
while all persons proposed for insurance are living and within 60 days
after 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 policy and premium interval applied for.
____________________________________
LIFE 1 DATE
-----------------------------------------
Not valid unless advance payment has
____________________________________ been made, the application is
LIFE 2 (IF SURVIVORSHIP) DATE 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 event of refund of payment)
Received from the Company, Boston, Massachusetts, the sum of $___________.
The amount mentioned in the receipt on the reverse side hereof.
Date________________________, __________ __________________________________
- --------------------------------------------------------------------------------
Page 12
REQUEST FOR AUTOMATIC DEDUCTION BILLING: PLEASE SEND COPY TO M SERVICE
Please make sure that the Automatic Deduction Authorization on Page 9 is
completed and signed.
Name of Insured ______________________ Policy 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 policy
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/Automatic Deduction Requests:
Firm ___________________
Producer _______________ Date __________________________
- --------------------------------------------------------------------------------
DETACH THIS SECTION AND GIVE TO CLIENT
JOHN HANCOCK VARIABLE LIFE INSURANCE COMPANY
Notice to Each 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
any 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
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 policy 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
- --------------------------------------------------------------------------------
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