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Exhibit 10
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OHIO NATIONAL LIFE ASSURANCE CORPORATION
VARIABLE LIFE INSURANCE APPLICATION SUPPLEMENT: SUITABILITY INFORMATION
Registered representatives are required to make inquiries and provide
information relating to the financial condition and retirement plans of the
purchasers of variable life contracts. Applicants are urged to supply such
information which, used with the insurance application, will allow the
registered representative to make an informed judgment as to the suitability
for a particular purchaser of variable life insurance. However, applicants
are not required to divulge such item or information. If the applicant
chooses not to do so, the registered representative must complete the
following items to the best of their knowledge. IF THE APPLICANT IS NOT THE
INSURED, QUESTIONS APPLY TO THE OWNER.
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1. Insured's Name_____________________________________ 8. Source of premium payment(s): (Check one or more)
Date of Birth______________________________ [ ] Current income [ ] Employer
(Owner's name and date of birth if not the Insured): [ ] Cash savings [ ] Relative
Owner's Name ____________________________ [ ] Securities presently held
Date of Birth ______________________________ [ ] Insurance or annuities cash values
[ ] Insurability or annuity value or death benefit
[ ] Sale of personal property or real estate
--------------------------------------------------------------------- [ ] Other ___________________________
2. Family members and/or dependents or Owner. --------------------------------------------------------------
Name Relationship Date of Birth
---------------------------------------------------------- 9. Approximate net worth of Owner?
________________________________________________ a. Liquid ___________________________
________________________________________________ b. Illiquid ____________________________
________________________________________________
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3. Spouse employed? 10. Marginal tax bracket:
[ ] Yes [ ] No Income $ ______________ [ ] 15% [ ] 28% [ ] 31% [ ] 36% [ ] 39.6%
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11. Applicant chooses not to divulge suitability
--------------------------------------------------------------------- information; any items shown above have been estimated
4. Insured's Occupation: by the registered representative.
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12. Telephone Transfers are authorized as described in the
--------------------------------------------------------------------- prospectus:
5. Name and Address of Owner's Employer:
No [ ] Yes [ ] Owner's Initials
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13 Registered representative's name
_________________________________
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6. Is owner or Insured employed by or associated with member OSJ SUITABILITY APPROVAL
of the NASD? [ ] Yes [ ] No
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________________________ Date _________________
7. Owner's annual income Principal
a. From employment $________________
b. From other sources $________________
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1. I have received the current prospectus for the Vari-Vest Survivor Variable
Life Insurance contract;
2. I have received a policy illustration demonstrating hypothetical results
based on anticipated premium payments and death benefits for Insured's age,
sex and underwriting class;
3. I UNDERSTAND THAT THE DEATH BENEFIT (EXCEPT SUPPLEMENTARY BENEFITS) MAY
INCREASE OR DECREASE DEPENDING ON THE CONTRACT'S INVESTMENT RETURN;
4. I UNDERSTAND THAT THE CASH VALUES MAY INCREASE OR DECREASE DEPENDING ON THE
CONTRACT'S INVESTMENT RETURN AND THAT THERE IS NO GUARANTEED MINIMUM CASH
VALUE;
5. I understand that any illustration of past historical investment returns is
not an indication of future investment performance.
6. I believe that this contract will meet my insurance needs and financial
objectives; and
7. Net premium payments (as described in the prospectus) should be allocated
to the General Account and/or the Subaccounts or portfolios as follows:
ALLOCATION OF NET PREMIUM
Allocation Split among Subaccounts
(Each must be a whole percent and total should be 100%)
________ % ___________ ________ % ___________ ________ % ___________
________ % ___________ ________ % ___________ ________ % ___________
________ % ___________ ________ % ___________ ________ % ___________
________ % ___________ ________ % ___________ ________ % ___________
________ % ___________ ________ % ___________ ________ % ___________
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Date Signature of Registered Signature of Applicant
Representative (Owner if other than Insured)
