EX-99.24(B)(5)(A) 4 b77429a1exv99w24xbyx5yxay.txt FORM OF SPECIMEN APPLICATION . . . 24(b)(5)(a) (JOHN HANCOCK(R) LOGO) NOT FOR USE IN NEW YORK JOHN HANCOCK ANNUITIES JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) P.O. Box 9505, Portsmouth, NH 03802-9505 Overnight mail: 164 Corporate Drive, Portsmouth, NH 03801-6815 800-344-1029 www.jhannuities.com Home Office: Bloomfield Hills, MI Application for [Venture 2010] Flexible Payment Deferred Annuity SIMPLIFY YOUR APPLICATION PROCESS ----------------------- SEE BACK PAGE FOR THE "GOOD ORDER CHECKLIST" APPVENIII0509 XXXX:120221
(JOHN HANCOCK(R) LOGO) JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) JOHN HANCOCK ANNUITIES P.O. Box 9505, Portsmouth, NH 03802-9505 Overnight mail: 164 Corporate Drive, Portsmouth, NH 03801-6815 800-344-1029 www.jhannuities.com Home Office: Bloomfield Hills, MI [Venture 2010] VARIABLE ANNUITY APPLICATION (Revised on [MM/YY)] ANNUITY PAYMENTS AND TERMINATION VALUES PROVIDED BY THIS CONTRACT ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNTS. ------------------------------------------------------------------------------------------------------------------------------------ 1 ACCOUNT REGISTRATION AND FUNDING (complete A or B) A. NONQUALIFIED REGISTRATION: [ ] Invdividual [ ] Trust [ ] Corporation [ ] Other _________________ --------------------------------------------------------------------------------------------------- FUNDING: DIRECT PAYMENT $ ______________ [ ] Check (Payable to John Hancock Life Insurance Company (U.S.A.)) Minimum $10,000 (Payment must accompany [ ] Wire (Please see sales kit or *ORIGINAL application if selected) jhannuities.com for wire instructions) TRANSFER/EXCHANGE PAPERWORK ----------------------------------------------------------------------------------------------------- MUST ACCOMPANY APPLICATION. TRANSFER/EXCHANGE* $ ___________ [ ] 1035 Exchange [ ] Mutual Fund / CD / Other SEE FORMS BOOKLET. ------------------------------------------------------------------------------------------------------------------------------- B. QUALIFIED REGISTRATION: [ ] Traditional IRA (Tax year ______) [ ] Roth IRA (Tax year ______) [ ] SEP IRA [ ] SIMPLE IRA [ ] Inherited/Beneficiary IRA (Optional death [ ] Individual 401(k) [ ] Other _________________ benefits and living benefit riders not permitted.) ---------------------------------------------------------------------------------------------------------------------------- FUNDING: DIRECT PAYMENT $ ______________ [ ] Check (Payable to John Hancock Life Insurance Company (U.S.A.)) Minimum $10,000 (Payment must accompany application if selected) [ ] Wire (Please see sales kit or jhannuities.com for wire instructions) ------------------------------------------------------------------------------------------------------------ TRANSFER/EXCHANGE* $ ___________ [ ] Direct Transfer [ ] Rollover ------------------------------------------------------------------------------------------------------------------------------------ 2 OWNER (oldest) ______________________________________________________________________________________ [ ] Male [ ] Female [ ] Trust/Entity Name (First, Middle, Last or Name of Trsut/Entity) __________________________ _________________________________________ [____________________________________________________] Date of Birth (mm/dd/yyyy) Social Security/Tax Identification Number Email Address _____________________________________________________________________________ _______________________________________________ Mailing Address City, State, Zip _____________________________________________________________________________ _______________________________________________ Residential Address (required if different from mailing or address is PO Box) Client Brokerage Account Number ------------------------------------------------------------------------------------------------------------------------------- CO-OWNER ______________________________________________________________________________________ [ ] Male [ ] Female [ ] Trust/Entity Name (First, Middle, Last or Name of Trsut/Entity) __________________________ _________________________________________ [____________________________________________________] Date of Birth (mm/dd/yyyy) Social Security/Tax Identification Number Email Address _____________________________________________________________________________ _______________________________________________ Mailing Address City, State, Zip _____________________________________________________________________________ Residential Address (Required if different from mailing or address is PO Box) ------------------------------------------------------------------------------------------------------------------------------------ 3 ANNUITANT (if different from owner) ______________________________________________________________________________________ [ ] Male [ ] Female [ ] Trust/Entity Name (First, Middle, Last or Name of Trsut/Entity) __________________________ _________________________________________ [____________________________________________________] Date of Birth (mm/dd/yyyy) Social Security/Tax Identification Number Email Address _____________________________________________________________________________ _______________________________________________ Mailing Address City, State, Zip _____________________________________________________________________________ Residential Address (Required if different from mailing or address is PO Box) ------------------------------------------------------------------------------------------------------------------------------- CO-ANNUITANT (if different from co-owner) ______________________________________________________________________________________ [ ] Male [ ] Female [ ] Trust/Entity Name (First, Middle, Last or Name of Trsut/Entity) __________________________ _________________________________________ [____________________________________________________] Date of Birth (mm/dd/yyyy) Social Security/Tax Identification Number Email Address _____________________________________________________________________________ _______________________________________________ Mailing Address City, State, Zip _____________________________________________________________________________ Residential Address (Required if different from mailing or address is PO Box) APPVENIII0509 Page 1 of 6 XXXX:120221
[Venture 2010] Application ------------------------------------------------------------------------------------------------------------------------------- 4 BENEFICIARIES THE PRIMARY If a co-owner was selected in Section 2, the surviving owner will be the primary beneficiary. BENEFICIARIES AND CONTINGENT Contingent beneficiaries receive proceeds only if all primary beneficiaries pre-decease the BENEFICIARIES MUST EACH owner. If you wish to restrict the death payment options for any of the beneficiaries listed EQUAL 100% OF PROCEEDS. below, please complete the Restricted Beneficiary Payout form located in our forms booklet or PLEASE USE WHOLE on www.jhannuities.com. PERCENTAGES ONLY. BENEFICIARY #1 [X] Primary _______________________________________________________ [ ] Male [ ] Female [ ] Trust/Entity Beneficiary's Name (First, Middle, Last or Name of Trust/Entity) _____________ _____________________ __________________________ _________________________________________ __________________ % of Proceeds Relationship to Owner Date of Birth (mm/dd/yyyy) Social Security/Tax Identification Number State of Residence ------------------------------------------------------------------------------------------------------------------------------- BENEFICIARY #2 [ ] Primary _______________________________________________________ [ ] Male [ ] Female [ ] Trust/Entity Beneficiary's Name (First, Middle, Last or Name of Trust/Entity) [ ] Contingent _____________ _____________________ __________________________ _________________________________________ __________________ % of Proceeds Relationship to Owner Date of Birth (mm/dd/yyyy) Social Security/Tax Identification Number State of Residence ------------------------------------------------------------------------------------------------------------------------------- BENEFICIARY #3 [ ] Primary _______________________________________________________ [ ] Male [ ] Female [ ] Trust/Entity Beneficiary's Name (First, Middle, Last or Name of Trust/Entity) [ ] Contingent _____________ _____________________ __________________________ _________________________________________ __________________ % of Proceeds Relationship to Owner Date of Birth (mm/dd/yyyy) Social Security/Tax Identification Number State of Residence ------------------------------------------------------------------------------------------------------------------------------- BENEFICIARY #4 [ ] Primary _______________________________________________________ [ ] Male [ ] Female [ ] Trust/Entity Beneficiary's Name (First, Middle, Last or Name of Trust/Entity) [ ] Contingent _____________ _____________________ __________________________ _________________________________________ __________________ % of Proceeds Relationship to Owner Date of Birth (mm/dd/yyyy) Social Security/Tax Identification Number State of Residence ------------------------------------------------------------------------------------------------------------------------------- BENEFICIARY #5 [ ] Primary _______________________________________________________ [ ] Male [ ] Female [ ] Trust/Entity Beneficiary's Name (First, Middle, Last or Name of Trust/Entity) [ ] Contingent _____________ _____________________ __________________________ _________________________________________ __________________ % of Proceeds Relationship to Owner Date of Birth (mm/dd/yyyy) Social Security/Tax Identification Number State of Residence ------------------------------------------------------------------------------------------------------------------------------- BENEFICIARY #6 [ ] Primary _______________________________________________________ [ ] Male [ ] Female [ ] Trust/Entity Beneficiary's Name (First, Middle, Last or Name of Trust/Entity) [ ] Contingent _____________ _____________________ __________________________ _________________________________________ __________________ % of Proceeds Relationship to Owner Date of Birth (mm/dd/yyyy) Social Security/Tax Identification Number State of Residence Note: To name additional beneficiaries, please use the space in Special instructions (Section 6). ------------------------------------------------------------------------------------------------------------------------------- 5 OPTIONAL DEATH BENEFITS Available at the time of application and cannot be cancelled once elected. Certain restrictions apply; please see the prospectus for details. [ ] ANNUAL STEP-UP DEATH BENEFIT (NOT AVAILABLE IF ANY OWNER IS AGE 75 OR OLDER.) ------------------------------------------------------------------------------------------------------------------------------- 6 SPECIAL INSTRUCTIONS (WRITE IN) APPVENIII0509 Page 2 of 6 XXXX:120221
[Venture 2010] Application ------------------------------------------------------------------------------------------------------------------------------- 7 USE THIS SECTION TO ELECT AN OPTIONAL LIVING BENEFIT RIDER [Skip to Section 8 if NO A. GUARANTEED LIVING BENEFITS Optional Living Benefit Rider is elected. GUARANTEED * For nonqualified LIVING BENEFITS PLEASE CHOOSE ONLY ONE RIDER: registrations (Section 1A), CANNOT BE CANCELLED ONCE ELECTED. the spouse must be either CERTAIN RESTRICTIONS APPLY; [ ] INCOME PLUS FOR LIFE the co-owner (Section 2) or SEE PROSPECTUS FOR DETAILS. sole primary beneficiary [ ] INCOME PLUS FOR LIFE-JOINT LIFE* (Section 4). For qualified registrations (Section 1B), [ ] PRINCIPAL PLUS FOR LIFE the spouse must be the sole primary beneficiary (Section 4).] ------------------------------------------------------------------------------------------------------------------------------- [B. INITIAL INVESTMENT OPTIONS FOR USE WITH GUARANTEED LIVING BENEFITS VARIABLE PORTFOLIOS REMEMBER: _____% MFC GIM Core Allocation _____% MFC GIM(1) Lifestyle Growth ANY COMBINATION OF _____% MFC GIM CORE FUNDAMENTAL HOLDINGS _____% MFC GIM(1) Lifestyle Moderate INVESTMENT OPTIONS WITHIN _____% MFC GIM Core Diversification _____% MFC GIM1 Money Market SECTION 7B MUST EQUAL 100%. _____% MFC GIM(1) Index Allocation _____% MFC GIM Core Balanced _____% MFC GIM(1) Lifestyle Balanced _____% MF GIM Core Global Diversification _____% MFC GIM(1) Lifestyle Conservative DOLLAR COST AVERAGING (Section 7C must be completed if elected) _____% 6 Month Fund OR _____% 12 Month Fund NOTE: Subsequent payments do not allocate to DCA Funds unless directed.] [100 % TOTAL INITIAL INVESTMENT OPTIONS (MUST EQUAL 100%)] ------------------------------------------------------------------------------------------------------------------------------- [C. DOLLAR COST AVERAGING INSTRUCTIONS Dollar Cost Averaging (DCA) is an optional program which involves the systematic transfer of specific dollar amounts each month from a Variable or DCA (6 or 12 month) Source Fund to one or more portfolios listed below. Automatic transfers run until the Source Fund has been depleted. START DATE [ ] IMMEDIATE OR [ ] 30 DAYS FROM ISSUE OR [ ]______* DAY OF MONTH (1-28) (DEFAULT IF NONE SELECTED) If the transfer day is a weekend, holiday or the 29th-31st, then the transfer will occur on the next business day. * If funds are received after the requested start date, transfers will begin on the requested day of the following month. SOURCE FUND [ ] 6 MONTH DCA FUND OR [ ] 12 MONTH DCA FUND OR (Selected in 7B) [ ] VARIABLE PORTFOLIO _________________________________________________________ MONTHLY Transfer Amount $__________________ (Variable Portfolio Source Fund ONLY.) DESTINATION FUND(S) AND % TO ALLOCATE _____% MFC GIM Core Allocation _____% MFC GIM(1) Lifestyle Growth _____% MFC GIM Core Fundamental Holdings _____% MFC GIM(1) Lifestyle Moderate _____% MFC GIM Core Diversification _____% MFC GIM(1) Money Market _____% MFC GIM(1) Index Allocation _____% MFC GIM Core Balanced _____% MFC GIM(1) Lifestyle Balanced _____% MFC GIM Core Global Diversification] _____% MFC GIM(1) Lifestyle Conservative [100 % TOTAL DCA OPTIONS (MUST EQUAL 100%)] Skip to Section 10 for State Disclosures. [(1) MFC Global Investment Management (U.S.A.) Limited] APPVENIII0509 Page 3 of 6 XXXX:120221
[Venture 2010] Application ------------------------------------------------------------------------------------------------------------------------------------ 8 USE THIS SECTION IF YOU ARE NOT ELECTING AN OPTIONAL LIVING BENEFIT RIDER A. INITIAL INVESTMENT OPTIONS (AVAILABLE WHEN NOT ELECTING AN OPTIONAL LIVING BENEFIT RIDER) [VARIABLE PORTFOLIOS _____% American Funds American Asset Allocation _____% MFC GIM(1) Mid Cap Index _____% American Funds American Bond _____% MFC GIM(1) Money Market _____% MFC GIM Core Allocation _____% MFC GIM(1) Pacific Rim _____% MFC GIM Core Diversification _____% MFC Global U.S. High Income _____% American Funds American Global Growth _____% PIMCO Global Bond _____% American Funds American Global Small Cap _____% PIMCO Total Return _____% American Funds American Growth _____% RCM/T. Rowe Price Science & Technology _____% American Funds American Growth-Income _____% T. Rowe Price Blue Chip Growth _____% American Funds American High-Income Bond _____% MFC GIM Core Balancd _____% American Funds American International _____% T. Rowe Price Equity-Income _____% American Funds American New World _____% T. Rowe Price Health Sciences REMEMBER: _____% Davis Financial Services _____% T. Rowe Price Small Company Value USE THIS PAGE ONLY _____% Davis Fundamental Value _____% Templeton(R) International Value WHEN NOT ELECTING _____% MFC GIM Core Diversification _____% UBS Global AM Global Allocation AN OPTIONAL LIVING _____% Franklin Templeton(R) International Small Cap _____% Van Kampen Value BENEFIT RIDER. _____% GMO International Core _____% MFC GIM Core Global Diversification _____% Invesco AIM/Munder Capital Small Cap Opportunities _____% Wellington Management Investment Quality Bond _____% Jennison Capital Appreciation _____% Wellington Management Mid Cap Intersection _____% Legg Mason Funds Management Core Equity _____% Wellington Management Mid Cap Stock _____% Marsico International Opportunities _____% Wellington Management Natural Resources _____% MFC GIM(1) Index Allocation _____% Wellington Management Small Cap Growth _____% MFC GIM(1) Lifestyle Aggressive _____% Wellington Management Small Cap Value _____% MFC GIM(1) Lifestyle Balanced _____% Western Asset High Yield _____% MFC GIM(1) Lifestyle Conservative _____% Western Asset Strategic Bond _____% MFC GIM(1) Lifestyle Growth _____% Western Asset U.S. Government Securities] _____% MFC GIM(1) Lifestyle Moderate [DOLLAR COST AVERAGING (Section 8B must be completed if elected) _____% 6 Month Fund OR _____% 12 Month Fund NOTE: Subsequent payments do not allocate to DCA Funds unless directed.] [100% TOTAL INITIAL INVESTMENT OPTIONS (MUST EQUAL 100%)] [(1) MFC Global Investment Management (U.S.A.) Limited] [B. DOLLAR COST AVERAGING INSTRUCTIONS (WHEN NOT ELECTING AN OPTIONAL LIVING BENEFIT RIDER) Dollar Cost Averaging (DCA) is an optional program which involves the systematic transfer of specific dollar amounts each month from a Variable or DCA (6 or 12 month) Source Fund to one or more portfolios listed above. Automatic transfers run until the Source Fund has been depleted. START DATE [ ] IMMEDIATE OR [ ] 30 DAYS FROM ISSUE OR [ ] _____ * DAY OF MONTH (1-28) (DEFAULT IF NONE SELECTED) If the transfer day is a weekend, holiday or the 29th - 31st, then the transfer will occur on the next business day. * If funds are received after the requested start date, transfers will begin on the requested day of the following month. SOURCE FUND [ ] 6 MONTH DCA FUND OR [ ] 12 MONTH DCA FUND OR (Selected in 8A) [ ] VARIABLE PORTFOLIO ____________________________________________________________ MONTHLY Transfer Amount $__________________ (Variable Portfolio Source Fund ONLY.) DESTINATION FUND(S) AND % TO ALLOCATE (Choose from Variable Portfolios located in section 8A.) _____% ________________________________ _____% ________________________________ Fund Name Fund Name _____% ________________________________ _____% ________________________________ Fund Name Fund Name _____% ________________________________ _____% ________________________________] Fund Name Fund Name [100% TOTAL DCA OPTIONS (MUST EQUAL 100%)] APPVENIII0509 Page 4 of 6 XXXX:120221
[Venture 2010] APPLICATION ------------------------------------------------------------------------------------------------------------------------------------ 9 REQUIRED FOR CALIFORNIA OWNER(S)/ANNUITANT(S) AGE 60 OR OLDER Under California law, there is a 30-Day Right to Review your contract. During this time, your initial payment may only be invested into a money market fund, unless you specifically direct that the initial payment be invested in other variable investment options. A.[ ] I/We wish to immediately invest in the variable investment options elected in either Section 7 IF YOU DO NOT CHECK or 8. If my/our contract is canceled within 30 days, the contract value will be returned to me/us. ONE OF THESE BOXES, WE MUST ALLOCATE YOUR PAYMENT B.[ ] I/We authorize the company to allocate my payment to the Money Market portfolio for a period of TO THE MONEY MARKET 35 calendar days. On the 35th day (or next business day) transfer my contract value to the PORTFOLIO (OPTION B). investment selection(s) elected in either Section 7 or 8. If I cancel my/our contract within 30 days, any payments will be returned. ------------------------------------------------------------------------------------------------------------------------------------ 10 ADDITIONAL STATE DISCLOSURES [FOR APPLICANTS IN ALL STATES EXCEPT AK, AZ, CO, DE, DC, FL, ID, IN, KY, MD, ME, NE, NJ, NM, OH, OK, OR, PA, TN, VA, VT, WA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. FOR AK APPLICANTS: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law. FOR AZ APPLICANTS: On written request, the Company is required to provide you, within a reasonable time, factual information regarding the benefits and provisions of your annuity contract. If, for any reason you are not satisfied with your annuity contract, you may return it within ten days, OR WITHIN THIRTY DAYS IF YOU ARE SIXTY-FIVE YEARS OF AGE OR OLDER ON THE DATE OF THE APPLICATION FOR YOUR ANNUITY CONTRACT, after the contract is delivered and receive a refund of all monies paid. For your protection, state law required the following statements to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. FOR CO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. FOR DE, ID, IN, OK APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive an insurance company files a statement of claim containing false, incomplete, or misleading information is guilty of a felony. FOR DC APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. FOR FL APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY ISSUER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. FOR KY, NE, PA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. FOR MD APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. FOR ME, TN, VA, WA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. FOR NJ APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. FOR NM APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. FOR OH RESIDENTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. FOR OR, VT RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.] ------------------------------------------------------------------------------------------------------------------------------------ 11 MILITARY SALES Is the annuitant or owner an active member of the U.S. Armed Forces? [ ] Yes* [ ] No (default) * If you answered "Yes", please complete and attach a "Military Personnel Financial Services Disclosure" form (available on www.jhannuities.com). This product is not specifically designed for or marketed to active duty military personnel. Applications not complying with our military sales procedures will not be accepted. APPVENIII0509 Page 5 of 6 XXXX:120221
[Venture 2010] APPLICATION ------------------------------------------------------------------------------------------------------------------------------------ 12 ACKNOWLEDGMENTS/SIGNATURES STATEMENT OF APPLICANT: I/We agree that the contract I/we have applied for shall not take effect until the later of: (1) the issuance of the contract, or (2) receipt by the company at its Annuity Service Office of the first payment required under the contract. The information herein is true and complete to the best of my/our knowledge and belief and is correctly recorded. [ ] YES* [ ] NO Does the annuitant or owner have existing individual life insurance policies or annuity contracts? [ ] YES* [ ] NO Will this contract replace or change any existing life insurance or annuity in this or any other company? * If you answered "YES" to either question, please complete below and attach a state replacement form (if applicable). Please see reference guide in the forms booklet. ________________________________________________________ _______________________________ [ ] Annuity [ ] Life Insurance Issuing Company Contract Number I/WE UNDERSTAND THAT UNLESS I/WE ELECT OTHERWISE, THE MATURITY DATE WILL BE THE LATER OF THE FIRST OF THE MONTH FOLLOWING THE ANNUITANT'S 90TH BIRTHDAY, OR 10 YEARS FROM THE CONTRACT DATE (IRAS AND CERTAIN QUALIFIED RETIREMENT PLANS MAY REQUIRE DISTRIBUTIONS TO BEGIN BY AGE 70 1/2). ALTERNATE MATURITY DATE_____________________________. I/WE ACKNOWLEDGE RECEIPT OF THE CURRENT PROSPECTUS AND UNDERSTAND THAT ANNUITY PAYMENTS AND OTHER VALUES PROVIDED BY THE CONTRACT APPLIED FOR, WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE VARIABLE INVESTMENT OPTIONS ARE VARIABLE AND ARE NOT GUARANTEED AS TO A FIXED DOLLAR AMOUNT. I/WE CONFIRM A REVIEW OF MY/OUR INVESTMENT OBJECTIVES, TAX, LIQUIDITY, AND FINANCIAL STATUSES WAS OFFERED TO ME/US. I/WE HAVE READ THE APPLICABLE FRAUD STATEMENT CONTAINED IN THE STATE DISCLOSURES SECTION. TO THE BEST OF MY KNOWLEDGE AND BELIEF, THE STATEMENTS IN THIS APPLICATION ARE TRUE AND COMPLETE. I/WE CERTIFY MY/OUR STATUS AS EITHER A CITIZEN OR RESIDENT ALIEN OF THE UNITED STATES OF AMERICA. SIGN OWNER: ____________________________________ __________________________________ ___________________ HERE Signature City, State (signed in) Date SIGN CO-OWNER: ____________________________________ __________________________________ ___________________ HERE Signature City, State (signed in) Date SIGN ANNUITANT: ____________________________________ __________________________________ ___________________ HERE (If different from owner) Signature City, State (signed in) Date SIGN CO-ANNUITANT: ____________________________________ __________________________________ ___________________ HERE (If different from co-owner) Signature City, State (signed in) Date ------------------------------------------------------------------------------------------------------------------------------------ 13 FINANCIAL ADVISOR INFORMATION A. CERTIFICATION: I HAVE TRULY AND ACCURATELY RECORDED THE INFORMATION PROVIDED BY THE APPLICANT AND I HAVE DETERMINED THAT THE ANNUITY CONTRACT APPLIED FOR IS A SUITABLE INVESTMENT FOR THE APPLICANT. [ ] YES [ ] NO Does the annuitant or owner have existing individual life insurance policies or annuity contracts? [ ] YES [ ] NO Will this contract replace or change any existing life insurance or annuity in this or any other company? [B. OPTION [ ] B [ ] C (If left blank, option will default to your firm's Selling Agreement.)] C. FINANCIAL ADVISOR (PRIMARY) _____________ % ________________________________________________ ___________________________________ ____________________ Percentage Printed Name Telephone Number State License ID __________________________________________ _________________________________ ______________________________________________ Broker/Dealer Firm Broker/Dealer Rep Number Email Address SIGN HERE ______________________________________________________________________________ Signature D. FINANCIAL ADVISOR (SECONDARY) _____________ % ________________________________________________ ___________________________________ ____________________ Percentage Printed Name Telephone Number State License ID __________________________________________ _________________________________ ______________________________________________ Broker/Dealer Firm Broker/Dealer Rep Number Email Address SIGN HERE ______________________________________________________________________________ Signature APPVENIII0509 Page 6 of 6 XXXX:120221