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[LOGO OF JOHN HANCOCK] John Hancock Variable Life Insurance Company,
Which will sometimes hereinafter be referred to as "the Company"
Regular Mail:
[John Hancock Variable Life Insurance Company
In order to complete the processing of your application, P.O. Box 62137
this form must be signed and either: Baltimore, MD 21264-2137]
1. Faxed to [(703) 443-8940] and the initial premium
mailed to the address at the right, or [Overnight Mail:
2. Mail both the signed application and the initial John Hancock Annuity Service Center
premium to the address at the right. 529 Main Street
Charlestown, MA 02129]
If you have any questions or need assistance with this form, please
[Variable Deferred Annuity Application] contact us at [1-877-569-3789]
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Note: Owner: Joint Owner:
Maximum age of
contract
owner is 85. -------------------------------------------------------- ----------------------------------------------------
Full Legal Name Full Legal Name
-------------------------------------------------------- ----------------------------------------------------
Street Address Street Address
-------------------------------------------------------- ----------------------------------------------------
Street Address (continued) Street Address (continued)
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City, State Zip City, State Zip
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Email Address/Phone Email Address
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Social Security # or Tax ID Social Security # or Tax ID
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Date of Birth Gender Date of Birth Gender
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Annuitant
(if other than
owner) --------------------------------------------------------
Full Legal Name
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Social Security # or Tax ID
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Date of Birth Gender
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Beneficiary
Information
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Name Social Security # or Tax ID
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Contract
Type [Non-Qualified, Traditional IRA, Roth IRA]
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156-DVA-00
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Variable During the Right To Cancel period any premiums will be allocated to the JH Money Market variable investment
Investment option. After the Right To Cancel period, please allocate my initial purchase payment of $__________ as follows:
Allocation
This allocation Each selection must be whole percentages and the total must equal 100%
will apply to
future [Variable Investment Options
purchase ----------------------------
payments
unless __% T. Rowe Price Large Cap Value __% JH Funds V.A. Strategic Income __% Wellington Small/Mid Cap Growth
otherwise __% Goldman Large Cap Value Core __% Wellington Large/Mid Cap Value __% MFS New Discovery Series
specified __% JH Funds V.A. Financial __% AIM V.I. Value __% Janus Aspen Worldwide Growth
through the Industries __% AIM V.I. Growth __% Rowe Price-Fleming International
Electronic __% State Street Equity Index __% Janus Aspen Global Technology Opportunities
Service Center __% Fidelity VIP Contrafund __% MFS Research Series __% Fidelity VIP Overseas Equity
__% Alliance Large Cap Aggressive __% Janus Mid Cap Growth __% Capital Guardian Global Balanced
Growth __% Boston Co. Small/Mid Cap Value __% JH Money Market
__% MFS Growth Series __% Goldman Small/Mid Cap CORE __% IIA Short-Term Bond
__% Capital Guardian Global Bond __% Capital Guardian Small Cap Equity __% JH Funds Active Bond]
__% Morgan Stanley Emerging __% JH Funds Small Cap Growth
Markets Equity
__% Wellington High Yield Bond
__% Fidelity VIP Growth
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Replacements Will the proposed contract replace any existing annuity or
insurance contract (including any John Hancock Life Insurance
Co. contracts), which have been or are being reduced in
premium amount, placed on paid-up, or surrendered?
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Annuitant/Insured on Existing Policy
---------------------------------------------------------------
Issuing Company
---------------------------------------------------------------
Address
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Policy No. Approximate Amount $
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Electronic If you agree, we will deliver all notices, documents, and other
Servicing information relating to your contract to your e-mail address
Center or, in some cases, to your personal account folder located at
[http://www.annuitynet.com](the "Electronic Servicing Center"),
until you revoke your consent. You may revoke your consent to
further delivery of electronic documents at any time by writing
to our Administrative Servicing Office. An electronic delivery
of notices, documents and information will be deemed to have
been made at the time that it is posted to your e-mail address
on record with the Company. We also reserve the right to
deliver documents to you on paper at any time should the need
arise.
To view, download, or print electronic documents, you must have
access to the Internet, maintain a valid e-mail address, and
install [Adobe Acrobat Reader] on your computer.
You may obtain a paper copy of any document relating to your
contract by writing to our Administrative Servicing Office.
Please indicate which documents you want to receive on paper
and provide us with your mailing address. We may charge a fee
for producing paper copies of documents that have been
delivered to you electronically.
You may update your e-mail address by contacting the Electronic
Servicing Center.
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Automatic Bank
Draft
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Bank name ABA Number
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Bank Street Address City, State Zip
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$
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Initial Amount Checking Account #
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Additional Monthly Amount Monthly Start Date
I/We hereby request and authorize you to pay and charge to
my/our account checks or electronic fund transfer debits
processed by and payable to the order of John Hancock
Variable Life Insurance Company, provided there are
sufficient collected funds in said account to pay the same
upon presentation. It will not be necessary for any officer
or employee of John Hancock Variable Life Insurance Co. to
sign such checks. I/We agree that your rights in respect to
each such check shall be the same as if it were a check drawn
on you and signed personally by me/us. This authority is to
remain in effect until revoked by me/us, and until you
actually receive such notice I/we agree that you shall be
fully protected in honoring any such check or electronic fund
transfer debit. In addition to regular bank draft, I/we
authorize such ad hoc drafts as are requested through the
Company's Servicing Office. I/We further agree that if any
such check or electronic fund transfer debit be dishonored,
whether with or without cause and whether intentionally or
inadvertently, you shall be under no liability whatsoever
even though such dishonor results in the forfeiture of
insurance or investment loss to me/us.
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Sign Here
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Signature(s) EXACTLY as shown on bank records
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Print full legal name(s) Date
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Signature(s) EXACTLY as shown on bank records
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Print full legal name(s) Date
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Special
Requirements
Section
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Authorizations/Consents and Taxpayer Identification Number
Certification
I/We acknowledge receipt of a current prospectus. I/We have
read and completed, as appropriate, all items contained in
this application and declare all statements are true to the
best of my/our knowledge and belief. I/We hereby certify to
the best of my/our knowledge and belief that the taxpayer
identification number(s), as listed on this Application, is
true and complete.
I/We hereby authorize John Hancock Variable Life Insurance
Company to accept any instructions received through the
Servicing Office from any person who can furnish proper
identification. I/We agree that John Hancock Variable Life
Insurance Co. is not liable for any loss arising from
following such instructions. If I/we are investing in this
Variable Annuity through a retirement plan or IRA, I/we
understand that I/we are not receiving any additional
tax-deferred benefit from the Variable Annuity.
I/We hereby agree to the terms and conditions of use
respecting the Electronic Servicing Center, and consent to
receive notices, documents, and other information relating
to the contract being applied for through the Electronic
Servicing Center as described above.
I/We acknowledge that the contractual payments and
accumulation values under the variable annuity provisions of
the contract being applied for are variable and are not
guaranteed as to fixed dollar amounts.
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Sign Here
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Signature of Contract Owner Date
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Full Name of Contract Owner
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Application Signed at (City and State)
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Signature of Joint Contract Owner Date
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Full Name of Joint Contract Owner
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State Disclosures
[For all states except CO, DC, KY, NJ, OH, OK, PA and VA:
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 may be guilty of insurance fraud.
For Arizona Residents Only:
On written request, we are required to provide within a reasonable time,
reasonable factual information regarding the benefits and provisions of the
annuity contract of yours. If for any reason, you are not satisfied with the
annuity contract you may return it within ten days after the contract is
delivered and receive a refund of all monies paid. For variable annuity
contracts, the refund shall equal the sum of the difference between the premiums
paid, including any policy or contract fees or other charges, and the amounts
allocated to any separate accounts under the policy or contract, and the value
of the amounts allocated to any separate accounts under the policy or contract
on the date the returned contract is received by the insurer or its agent.
For District of Columbia Residents only:
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 Kentucky Residents only:
Any person who knowingly and with the intent to defraud any insurance company or
other persons, submits an application or files a statement of claim containing
any materially false information, or conceals for the purpose of misleading,
information concerning any facts, material thereto, commits a fraudulent act,
which is a crime.
For New Jersey Residents only:
Any person who includes any false or misleading information on an application
for an insurance policy is subject to criminal and civil penalties.
For Ohio Residents only:
Any person who knowingly and with intent to defraud any insurance company or
other persons, submits an application or files a claim containing any materially
false information, or conceals for the purpose of misleading, information
concerning any facts, material thereto, commits a fraudulent act, which is a
crime.
For Oklahoma Residents only:
WARNING: Any person who knowingly and with intent to injure, defraud, or deceive
any insurer, makes a claim for the proceeds of an annuity containing any false,
incomplete or misleading information is guilty of a felony.
For Pennsylvania Residents only:
Any person who, knowingly and with intent to defraud any insurance company or
other person, files an application for insurance or statement of claim
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 Virginia Residents only:
Any person who, with the 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 may have violated state law.]
156-DVA-00
