EX-99.27(E)(1) 11 dex9927e1.txt APPLICATION [LOGO OF JOHN HANCOCK] Draft 4 - March 20, 2006 [GRAPHIC APPEARS HERE] Policy Details - Variable Life [ ] John Hancock Life Insurance Company (U.S.A.) [ ] John Hancock Variable Life Insurance Company (hereinafter referred to as The Company) Service Office: 200 BLOOR STREET EAST TORONTO, ONTARIO CANADA M4W 1E5 . This form is part of the Application for Life Insurance for the Proposed Life Insured(s). . Print and use black ink. Any changes must be initialed by the Proposed Life Insured(s) and/or Owner(s). Proposed Life Insured (Life One) Proposed Life Insured (Life Two) Name First Middle Last Name First Middle Last __________________________________ __________________________________ Name(s) of Owner(s) __________________________________________________________ __________________________________________________________ Plan Name Single Life [ ] Majestic VUL 98 [ ] Majestic Performance VUL [ ] Majestic Variable COLI [ ] Variable MasterPlan Plus Survivorship Life [ ] Majestic VEP 98 [ ] Majestic Performance Survivorship VUL Other ____________________________________________________________ Amount 1. Base Sum Insured (BSI) or Base Face Amount (BFA) $______ Additional Sum Insured (ASI) or Supplemental Face Amount (SFA) on Page 2. Premiums 2.Frequency: [ ] Annual [ ] Semi-Annual [ ] Quarterly [ ] Monthly - (Automatic Deduction) [ ] Other _______________________________________________________ Premium Notices and Correspondence 3. a) Send [ ] [ ]Life One [ ]Life Two Premium Owner(s) Notices to: [ ] Employer's [ ] Other: Name & Address (details below) Address Name ____________________________________________________________ Street No. & Name, Apt No., City, State, Zip code ____________________________________________________________ b)Send [ ] Same as Premium Notices (as [ ] Other: Name & Correspondence above) Address to: (details below) Name ____________________________________________________________ Street No. & Name, Apt No., City, State, Zip code ____________________________________________________________ Additional Benefits 4. a) Life Insurance Qualification Test [ ] Guideline Premium (GPT) [ ] Cash Value Accumulation (CVAT) Note: Elected test cannot be changed after the policy is issued. You may request an Illustration on both tests before making your election. b) Death Benefit Option [ ] Option A/Option 1(Face Amount) [ ] Option B/Option 2 (Face Amount plus Account/Policy Value) [ ] Option M (Available on Majestic VUL 98 and Majestic VEP 98 if CVAT Chosen) with calculation beginning in policy year ____ NB5008US (M) Page 1 of 5 M Proprietary Variable NB5008US (05/2006) Majestic Products Additional Sum Insured (ASI), Supplemental Face Amount (SFA) and Premium Schedules 5. [ ] Additional Sum Insured(ASI)/Supplemental Face Amount(SFA) Check only one option below. a) [ ] ASI/SFA of $____ [ ] For Life of Policy [ ] With Face Amount (TSI/TFA) of $____ increasing by __% or $____ Per Year for [ ] Life of Policy or __ Policy Years b) [ ] Customized Level or Increasing Schedule List by policy year or years. ASI/SFA amount may not decrease. Policy Year(s) ASI/SFA Amount -------------- ----------------------------------------- to $ (1) to $ (2) to $ (3) to $ (4) to $ (5) to $ (6) to $ (7) to $ (8) to $ (9) to $ (10) (If more space is required, complete and attach form NB5064.) 6. [ ] Planned Premium a) [ ] $______ annually for _____ year(s) [ ] Annual Increase of __% [ ] Additional first year Planned Premium $______ b) [ ] Customized Schedule List by policy year(s). Policy Year(s) Planned Premium Amount -------------- ----------------------------------------- to $ (1) to $ (2) to $ (3) to $ (4) to $ (5) to $ (6) to $ (7) to $ (8) to $ (9) to $ (10) (If more space is required, complete and attach form NB5064.) Majestic VUL 98, Majestic Variable COLI, Variable MasterPlan Plus, Majestic VEP 98 7. [ ] Living Care Benefit (for terminal illness, only available on Majestic VUL 98 ) [ ] Enhanced Cash Value Rider [ ] Premium Cost Recovery for [ ] Life of Policy [ ] __ Policy Years [ ] Age 100 Waiver of Charges Rider (Not available on MVCOLI or VMPP) [ ] Policy Split Option Rider (Only available on Majestic VEP 98) [ ] Continuation of Guaranteed Minimum Death Benefit Option after 10th Policy Year (Only available with Option A) [ ] Other _________________________________________________________________ Majestic Performance VUL 8. [ ] Enhanced Surrender Value Rider [ ] LifeCare Benefit Rider (Please complete form NB5018.) [ ] Extended No Lapse Guarantee [ ] LifeCare Benefit Max (LMAX) (beyond Basic Period) Extension Rider [ ] To Age ____ [ ] Period _____ [ ] Accelerated Benefit Rider [ ] Return of Premium Death Benefit [ ] Other (with DB Option 1 only) Increase Rate [ ] Yes __% [ ] No Percentage of Premiums to be returned at death (Whole numbers only. Maximum 100%) __ % Majestic Performance Survivorship VUL 9. [ ] Enhanced Cash Value Rider [ ] Premium Cost Recovery for [ ] Life of Policy [ ] __ Policy Years [ ] Survivorship Four Year Level Term Rider [ ] Policy Split Option Rider [ ] Other _________________________________________________________________ NB5008US (M) Page 2 of 5 M Proprietary Variable NB5008US (05/2006) Majestic Products Additional Information - These questions apply to the OWNER(S) of the policy. All questions must be answered. 10. a) If an additional or optional policy is being applied for in a separate application, state plan and amount. Plan name ___________________________________________________________ $______ b) Do you understand that you may need to pay premiums in addition to Planned Premium if the current policy charges or actual investment performance are different from the assumptions used in your Illustration (assuming the requirements of any applicable guaranteed death benefit feature have not been satisfied)? Yes No 11. Have you received a current prospectus (and any supplements) for the applicable policy? [ ] Yes [ ] No If Yes, date of prospectus(es) mmm dd yyyy _______ _______ ___ Date of supplement(s) mmm dd yyyy _______ _______ ___ Date of John Hancock Trust prospectus (if applicable) mmm dd yyyy _______ _______ ___ Date of supplement mmm dd yyyy _______ _______ ___ 12. With the above in mind, does the policy meet your insurance objectives and your anticipated financial needs? [ ] Yes [ ] No Investor Suitability Statements 13.I UNDERSTAND THAT UNDER THE APPLIED FOR POLICY: (A)THE AMOUNT OF THE INSURANCE BENEFITS, OR THE DURATION OF THE INSURANCE COVERAGE, OR BOTH, MAY BE VARIABLE OR FIXED. (B)THE AMOUNT OF THE INSURANCE BENEFITS, THE DURATION OF THE INSURANCE COVERAGE, AND THE POLICY/ACCOUNT VALUE, MAY INCREASE OR DECREASE DEPENDING ON THE INVESTMENT EXPERIENCE OF THE CHOSEN INVESTMENT ACCOUNTS AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. ILLUSTRATIONS OF BENEFITS, INCLUDING DEATH BENEFITS, POLICY/ACCOUNT VALUES AND CASH SURRENDER VALUES ARE AVAILABLE ON REQUEST. (C)THE ENTIRE INVESTMENT COULD BE LOST BECAUSE OF THE PERFORMANCE OF THE INVESTMENT FUND AND IN THE ABSENCE OF ADDITIONAL PREMIUM PAYMENT, THE INSURANCE COVERAGE COULD LAPSE. Telephone/Allocation Change Authorization 14.I understand and agree that: a) Telephone transfers and allocation changes will also be subject to the conditions of the policy, the administrative requirements of The Company, and the provisions of the policy's prospectus. b) The Company may act on telephone instructions from the Owner or from any such person, if the policy is jointly owned. The Company, its agents, or representatives of employees who act on its behalf, will not be subject to any claim, liability, loss, expense or cost if it acted on good faith upon telephone instructions it reasonably believes to be genuine in reliance on this signed authorization. The Company will employ reasonable procedures to confirm that the instructions communicated by telephone are genuine. Such procedures shall consist of confirming a valid telephone authorization form is on file and providing written confirmation of tape recorded instructions. c) The Company, at its option alone and without prior or subsequent notice to the Owner(s), or any other person or representative of the Owner(s), may record all or part of any telephone conversation containing telephone transfer and/or allocation change instructions. d) All terms of authorization are binding upon the agents, heirs and assignees of the Owner(s). e) This Telephone/Allocation Change Authorization will be effective until such time as (a) written revocation is received by The Company's Service Office, or (b) The Company discontinues this privilege, whichever occurs first. Please check [X] ONLY one box: [ ] I authorize The Company to accept telephone instructions from me or any co-owner. [ ] I authorize The Company to accept telephone instructions from me, any co-owner or our Registered Representative. (Registered Representatives should contact their broker/dealer for procedures regarding this authorization.) NB5008US (M) Page 3 of 5 M Proprietary Variable NB5008US (05/2006) Majestic Products 15.INVESTMENT ALLOCATION OF NET PREMIUMS - Allocation must be whole numbers. Total must be 100%. Majestic VUL 98, Majestic Performance VUL, Majestic Variable COLI, Variable MasterPlan Plus, Majestic VEP98, Majestic Performance Survivorship VUL AGGRESSIVE GROWTH PORTFOLIOS __% Science & Technology __% Pacific Rim __% Health Sciences __% Emerging Growth __% Small Cap Growth __% Emerging Small Company __% Small Cap __% Small Cap Index __% Dynamic Growth __% Mid Cap Stock __% Natural Resources __% All Cap Growth __% Strategic Opportunities __% Financial Services __% International Opportunities __% International Small Cap __% International Equity Index B __% Overseas Equity __% American International __% International Value __% International Core __% FIXED ACCOUNT NOTE: Liquidity restrictions apply when allocating funds to the Fixed Account. GROWTH PORTFOLIOS __% Quantitative Mid Cap __% Mid Cap Index __% Mid Cap Core __% Global __% Capital Appreciation __% American Growth __% U.S. Global Leaders Growth __% Quantitative All Cap __% All Cap Core __% Total Stock Market Index __% Blue Chip Growth __% U.S. Large Cap __% Core Equity __% Strategic Value __% Large Cap Value __% Classic Value __% Utilities __% Real Estate Securities __% Small Cap Opportunities __% Small Cap Value __% Small Company Value __% Special Value __% Mid Value __% Mid Cap Value __% Value __% All Cap Value M FUNDS __% Brandes International Equity __% Turner Core Growth __% Frontier Capital Appreciation __% Business Opportunity Value OTHER PORTFOLIO __% ______________________________ GROWTH & INCOME PORTFOLIOS __% Growth & Income __% 500 Index B __% Fundamental Value __% U.S. Core __% Large Cap __% Quantitative Value __% American Growth - Income __% Equity - Income __% American Blue Chip Income & Growth __% Income & Value __% Managed __% PIMCO VIT All Asset __% Global Allocation INCOME PORTFOLIOS __% High Yield __% U.S. High Yield Bond __% Strategic Bond __% Strategic Income __% Global Bond __% Investment Quality Bond __% Total Return __% American Bond __% Real Return Bond __% Bond Index B __% Core Bond __% Active Bond __% U.S. Government Securities __% Short Term Bond CONSERVATIVE PORTFOLIO __% Money Market B LIFESTYLE PORTFOLIOS __% Lifestyle Aggressive __% Lifestyle Growth __% Lifestyle Balanced __% Lifestyle Moderate __% Lifestyle Conservative NB5008US (M) Page 4 of 5 M Proprietary Variable NB5008US (05/2006) Majestic Products Allocation of Monthly Charges 16.Please deduct the monthly charges from the following accounts (except Mortality and Expense Risk/Asset based Risk charges). Account No. __________________________ __% [ ] Check box and attach sheet with additional __________________________ __% information, if necessary. Owner(s) Signature(s) Signed at City State This Day of Year ____________________________ _______ ____________________________ ________ Signature of Witness/Registered Representative (as Witness) Signature of Owner X X ___________________________________ ______________________________________ Signature of Owner X ______________________________________ Agent/Registered Representative Certification - All Agents/Registered Representatives sharing commissions must sign this form. I certify that a current prospectus (and any supplement) for the policy applied for has been given to the Proposed Life Insured(s), and to the Owner(s) if other than the Proposed Life Insured(s). Signature of Agent/Registered Representative Place and Date X _____________________________________ ______________________________________ Signature of Agent/Registered Representative Place and Date X _____________________________________ ______________________________________ Signature of Agent/Registered Representative Place and Date X _____________________________________ ______________________________________ Signature of Agent/Registered Representative Place and Date X _____________________________________ ______________________________________ Signature of Agent/Registered Representative Place and Date X _____________________________________ ______________________________________ NB5008US (M) Page 5 of 5 M Proprietary Variable NB5008US (05/2006) Majestic Products