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This application for life Insurance is to (check one):
[_] John Hancock Life Insurance Company
[_] 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
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A. PROPOSED INSURED
1. Name of Proposed Insured (please print): 4. Social Security Number: ___________ - __________ - __________
First _____________________________ MI _______ 5. Address: _____________________________________________________
STREET ADDRESS
Last ________________________________________ ______________________________________________________________
2. Sex: [_] Male [_] Female CITY STATE ZIP
3. Date of Birth: ____/____/____ 6. Name of Employer: ____________________________________________
B. PLAN
[_] Majestic Variable COLI [_] Majestic UL COLI [_] Variable MasterPlan Plus
[_] Majestic VUL 98 [_] Majestic UL [_] Other
C. BENEFITS D. ADDITIONAL BENEFITS
(IF AVAILABLE ON PLAN SELECTED IN B. ABOVE)
1. Basic Sum Insured (BSI) $ _____________________ 1. [_] Continuation of Guaranteed Minimum Death Benefit
Option after 10/th/ Policy Year (not available Option B)
2. Death Benefit Option (choose one)
[_] Option A- Sum Insured Only 2. [_] Enhanced Cash Value Rider
[_] Option B- Sum Insured plus Account Value
3. [_] Other
3. Definition of Life Insurance Test: (chose one)
[_] Cash Value Accumulation [_] Guideline Premium
4. Additional Sum Insured (ASI) (check if desired) E. PREMIUM
a.) (Check no more than one of the following)
[_] ASI of $ ____________________________ 1. Premium Billing Interval
[_] for life of policy.
[_] with Total Sum Insured $ _________increasing by [_] Annual [_] Semiannual [_] Quarterly [_] Monthly
[_] ___ % or [_] $ _________ per year for
[_] life of policy or [_] _______ policy years. 2. Planned Premium (check a or b, or Target Premium will be
[_] Customized Level or Increasing Schedule billed.)
(list by policy year or years, ASI amount may not
decrease) a.) [_] $ __________ annually for _____ year(s)
Optional: Annual Increase of ____% OR
$ __________ annually for _____ year(s)
Additional first year Planned Premium $__________
b.) [_] Customized Schedule (list by policy year or years):
Policy Year(s) ASI Amount
-------------- ---------- Policy Year(s) ASI Amount
____ - ____ $ ______________ (1) -------------- ----------
____ - ____ $ ______________(1)
____ - ____ $ ______________ (2)
____ - ____ $ ______________(2)
____ - ____ $ ______________ (3)
____ - ____ $ ______________(3)
____ - ____ $ ______________ (4)
____ - ____ $ ______________(4)
____ - ____ $ ______________ (5)
____ - ____ $ ______________(5)
____ - ____ $ ______________ (6)
____ - ____ $ ______________(6)
____ - ____ $ ______________ (7)
____ - ____ $ ______________(7)
____ - ____ $ ______________ (8)
____ - ____ $ ______________(8)
____ - ____ $ ______________ (9)
____ - ____ $ ______________(9)
____ - ____ $ ______________ (10)
____ - ____ $ ______________(10)
(If more space needed, attach separate schedule.)
b.) [_] Premium Cost Recovery (If more space needed, attach separate schedule.)
[_] for life of policy or [_] ________ policy years
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F. OWNER
1. Owner (if other than Proposed insured) (check only one): Complete questions 4-6 if Owner is a Trust
[_] Individual(s) [_] Corporation [_] Trust 4. Name of Trust:
____________________________________________________________ _______________________________________________________
____________________________________________________________ _______________________________________________________
____________________________________________________________ _______________________________________________________
____________________________________________________________ _______________________________________________________
____________________________________________________________ _______________________________________________________
2. Owner's Address: 5. Trustee(s):
____________________________________________________________ _______________________________________________________
____________________________________________________________ _______________________________________________________
____________________________________________________________ _______________________________________________________
____________________________________________________________ _______________________________________________________
____________________________________________________________ _______________________________________________________
3. Tax I.D. or Soc. Sec. #: ____________________________ 6. Date of Trust: ______/_______/______
G BENEFICIARY
Please indicate full name and relationship to the Proposed Insured. (please
print)
The right to change the beneficiary as to any proceeds is reserved to the
Owner(s).
H. UNDERWRITING INFORMATION
1. During the past 3 months, has the Proposed Insured been
actively at work on a full-time basis, at least 30 hours
per week in a normal capacity, and not been absent for
more than 5 consecutive days due to illness or medical
treatment? If no, give details below. [_] Yes [_] No
2. Within the last 12 months, has the Proposed Insured used
tobacco (cigarettes, cigars, chewing tobacco, pipe, etc.)
or any other substance containing nicotine, including
Nicorette gum? If yes, give Yes details below. [_] Yes [_] No
3. Details:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
I. SPECIAL REQUESTS
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J. SUBACCOUNT INVESTMENT OPTIONS (Complete only if different than options
elected in Master Application)
Percentages must be Whole and Total 100%
Equities (Mid Cap) International/Global Equities Cash Equivalents/Fixed Account
______% Fundamental Mid Cap Growth ___% Emerging Markets Equity ___% Money Market
______% Mid Cap Value II ___% Global Balanced ___% Fixed Account*
______% Mid Cap Growth ___% International Equity Index
______% Real Estate Equity ___% International Opportunities Outside Trust Funds
______% Small/Mid Cap CORE __% AIM V.I. Value
______% Small/Mid Cap Growth Bonds __% Fidelity VIP Contrafund
___% Active Bond __% Fidelity VIP Growth
Equities (Large Cap) ___% Bond Index __% Janus Aspen Global Technology
___% Large Cap Value Core II ___% Active Bond II __% Janus Aspen Worldwide Growth
___% Equity Index ___% Global Bond __% MFS New Discovery
___% Growth & Income ___% High Yield Bond __% Templeton International Securities
___% Short Term Bond
___% Managed Other (if available)
___% Large Cap Aggressive Growth M Proprietary __% ________________________________
___% Large Cap Growth __% Brandes International Equity Fund __% ________________________________
___% Large Cap Value __% Enhanced U.S. Equity Fund __% ________________________________
__% Frontier Capital Appreciation __% ________________________________
Equities (Small Cap) __% Turner Core Growth __% ________________________________
___% Small Cap Growth
___% Small Cap Value]
*Liquidity restrictions apply when allocating funds to the Fixed Account
K DISCLOSURES
1. Have you received a prospectus for the policy applied for? [_] Yes [_] No
(If YES, Prospectus Date:____________)
2. Do you understand that the amount of Death Benefit and the [_] Yes [_] No
entire amount of the account value may increase or decrease
depending on investment experience?
3. Is the policy and allocation of subaccounts in accord with the [_] Yes [_] No
applicable insurance objectives and anticipated financial needs?
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AGREEMENTS, AUTHORIZATIONS and SIGNATURES
A. The statements and answers in this 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 will be used to form
the basis of and be a part of any new life insurance policy to be issued. The
information in this application will be used to determine eligibility for
insurance
B. I authorize any medical practitioner or facility, insurance company, consumer
reporting agency, motor vehicle record agency, and the Medical Information
Bureau to give the Company or its representative any medical or motor vehicle
information it has in its records on me to use for underwriting my insurance
and for claims purposes. I, or my authorized representative, am entitled to
receive a copy of this authorization. I acknowledge receipt of the Federal
Fair Credit Reporting Act Notice, which, on the reverse side, contains a
notice concerning the Medical Information Bureau. A photocopy of this
authorization is as valid as the original and is valid for 24 months. A faxed
signature is deemed as good as an original.
C. 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 thereupon and (2) only
if at the time of such delivery and payment the Proposed Insured in part A of
this application is living. D. 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.
E. All benefits, payments, and values, including the Death Benefit and Account,
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 may even decrease to
zero.
F. The registered representative's signature below certifies that a current
prospectus for the policy applied for has been given to the Proposed Insured
and/or to the Applicant and that no written sales materials other than those
approved by the Company have been used.
G. I understand that any person who, with intent to defraud or knowing that he
is facilitating a fraud against an insurer, submits an application or files a
claim containing a false or deceptive statement is guilty of insurance fraud.
__________________________________________________________________________________________________________________________________
Signature of Proposed Insured Signed at City or Town State Date
__________________________________________________________________________________________________________________________________
Signature of Applicant/Owner Signed at City or Town State Date
__________________________________________________________________________________________________________________________________
Signature of Witness (Registered Representative's License #) Date
(Registered Representative must witness where required by law)
TAXPAYER IDENTIFICATION NUMBER
The Internal Revenue Service (IRS) does not require your consent to any
provision of this document, other than the certification required to avoid
backup withholding.
Under penalty of perjury, I certify that (i) the number shown in item 4 of
Section A (or item 3 of Section F if the Proposed Insured is not the Owner) of
this form is my correct taxpayer identification number, AND (ii) I am not
subject to backup withholding because (a) I am exempt from backup withholding,
or (b) I have not been notified by the IRS that I am subject to backup
withholding as a result of failure to report all interest and dividends, or (c)
the IRS has notified me that I am no longer subject to backup withholding.
__________________________________________________________________________________________________________
Signature of Owner/ Taxpayer Date
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M Proprietary Products
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