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
2. Family members and/or dependents or Owner. Insurability or annuity value or death benefit
NAME RELATIONSHIP DATE OF BIRTH Sale of personal property or real estate
________________________________________________ Other ___________________________
________________________________________________ 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 by the
--------------------------------------------------------------------- registered representative.
4. Insured's Occupation:
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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 V 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 Representative Signature of Applicant (Owner if other than Insured)
