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THE MANUFACTURERS LIFE INSURANCE COMPANY OF NORTH AMERICA
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[MANULIFE FINANCIAL LOGO] [VENTURE LOGO]
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Flexible Payment Deferred Combination Fixed and Variable Annuity Application.
Payment (or original of exchange/transfer request) must accompany Application.
Please make check payable to MANULIFE NORTH AMERICA (the "Company") and address
to: X.X. XXX 0000, XXXXXX, XX 00000-0000. 000-000-0000
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1. Account Registration (Please Print)
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Owner (Applicant-Must be completed)
Name*
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First Middle Last
Address
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Street
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City State Zip
Sex / /M / /F Date of Birth / / / / / /
Month Day Year
Daytime Phone Number: ( )
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/ / / / / / / / / / or / / / / / / / / / /
Social Security Number Tax ID Number
Client Brokerage Acct.#:
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Co-Owner (Complete if applicable)
Name*
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First Middle Last
Sex / /M / /F Date of Birth / / / / / /
Month Day Year
/ / / / / / / / / / or / / / / / / / / / /
Social Security Number Tax ID Number
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Annuitant (If different from Owner)
Name*
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First Middle Last
Address
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Street
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City State Zip
Sex / /M / /F Date of Birth / / / / / /
Month Day Year
/ / / / / / / / / /
Social Security Number
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Co-Annuitant (Complete if applicable)
Name*
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First Middle Last
Sex / /M / /F Date of Birth / / / / / /
Month Day Year
/ / / / / / / / / /
Social Security Number
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Group Holder (NJ, PA, SC, TX, WA Only)
In certain states, certificates are issued under a
Master Group contract.
Name Venture Trust
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Address G706114/G706115
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2. INVESTMENT ALLOCATION
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$ Allocate payment with application as indicated below (must total
100%) (Minimum initial payment of $2,000 qualified; $5,000 non-qualified):
Payment Method: / / Check / / Wire / / 1035 Exchange
/ / Transfer/Rollover / / Other
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% MAC Pacific Rim Emerging Markets (008)
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% **Xxxxxxx Xxxxx Developing Capital Markets Focus (117)
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% X. Xxxx Price Science & Technology (016)
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% Founders Int'l Small Cap (006)
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% AIM Aggressive Growth (022)
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% Franklin Emerging Small Company (020)
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% CGTC Small Company Blend (070)
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% AIM Mid Cap Growth (011)
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% Wellington Management Mid Cap Stock (074)
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% Fidelity Overseas (013)
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% Xxxx Xxxxx-Xxxxxxx Int'l Stock (024)
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% Xxxxxxxxx Int'l Value (078)
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% Fidelity Mid Cap Blend (001)
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% AXA Xxxxxxxxx Small Company Value (119)
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% MSAM Global Equity (009)
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% **Xxxxxxx Xxxxx Special Value Focus (116)
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% SSgA Growth (005)
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% Fidelity Large Cap Growth (004)
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% MAC Quantitative Equity (065)
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% X. Xxxx Price Blue Chip Growth (012)
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% MAC Real Estate Securities (068)
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% MAS Value (066)
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% **Xxxxxxx Xxxxx Basic Value Focus (115)
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% Wellington Management Growth & Income (017)
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% CGTC U.S. Large Cap Value (064)
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% X. Xxxx Price Equity-Income (007)
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% CGTC Income & Value (003)
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% Founders Balanced (071)
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% MAS High Yield (076)
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% SaBAM Strategic Bond (015)
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% PIMCO Global Bond (010)
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% PIMCO Total Return (174)
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% Wellington Management Inv Quality Bond (018)
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% CGTC Diversified Bond (002)
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% SaBAM U.S. Gov't Securities (014)
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% MAC Money Market (019)
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Lifestyle Portfolios
% Aggr 1000 (183) % Growth 820 (182)
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% Bal 640 (181) % Mod 460 (180)
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% Cons 280 (179)
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Fixed Accounts
Fixed accounts not available in WA if GRIP is elected.
(1) 3-, 5- and 7-year fixed accounts are not available in FL, MD, OR.
% 1 Yr (021) % 3 Yr (023) (1)
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% 5 Yr (025) (1) % 7 Yr (027) (1)
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**These portfolios are not available for any ERISA governed plan.
*Unless subsequently changed in accordance with terms of Contract issued.
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3. BENEFICIARIES (Enclose signed letter if more information is required.)
Name*
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First Middle Last Relationship %
Date of Birth / / / / / / / / / / / / / / / /
Month Day Year Social Security Number
Name*
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First Middle Last Relationship %
Date of Birth / / / / / / / / / / / / / / / /
Month Day Year Social Security Number
Contingent Beneficiary
Name*
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First Middle Last Relationship
Date of Birth / / / / / / / / / / / / / / / /
Month Day Year Social Security Number
4. RIDERS (Optional)
/ /No / /Yes GRIP (Guaranteed Retirement Income Program)
(Irrevocable) Not available in all states.
Do you choose to elect the Guaranteed Retirement Income
Program (GRIP) benefit?
If "Yes," there is an additional 0.25% annual fee, charged
on each contract anniversary. See prospectus for details.
Fixed accounts not available in WA if GRIP is elected.
5. PLAN SPECIFICS (Must be completed)
Type of Plan: / / Non-Qualified (minimum $5,000)
/ / 1035 Exchange, Cost Basis $---------
Qualified / / XXX Tax Year ------- / / Simple XXX
(minimum $2,000) / / XXX Rollover / / SEP XXX
/ / XXX Transfer / / Xxxx XXX
/ / Xxxxx (HR-10) / / 401(k)
/ / 403(b) Check if ERISA / / / / 457
/ / Money Purchase / / Defined Benefit
/ / Profit Sharing
/ / Other -----------
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/ / No / / Yes Has Annuitant or applicant(s) any existing annuities or
insurance?
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/ / No / / Yes Will the purchase of this Annuity replace or change any
other insurance or annuity?
If "Yes," state company and contract number in Remarks,
and attach replacement forms.
If 1035 exchange, or any other transfer of assets, attach
original of exchange form or letter.
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Remarks:
6. SIGNATURES (All participants must sign application, including Irrevocable
Beneficiary, if designated.)
Notice to Applicant: FOR FLORIDA RESIDENTS ONLY: Any person who knowingly and
with intent to injure, defraud, or deceive any insurer 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 NEW JERSEY RESIDENTS ONLY: Any person who includes any false or misleading
information on an insurance policy is subject to criminal and civil penalties.
FOR ARKANSAS, KENTUCKY, MAINE, NEW MEXICO, OHIO AND PENNSYLVANIA RESIDENTS ONLY:
Any person who knowingly and with intent to defraud any insurance company or
other person files an application or submits a 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.
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. I/We agree to be
bound by the representations made in this application. The Contract I/we have
applied for is suitable for my/our insurance investment objectives, financial
situation and needs. I/We understand that unless I/we/elect otherwise in the
Remarks section, the Maturity Date will be the later of the Annuitant's 85th
birthday, or 10 years from the Contract Date (IRAs and certain qualified
retirement plans may require distributions to begin by age 70-1/2).
I/WE ACKNOWLEDGE RECEIPT OF THE MOST CURRENT PROSPECTUS AND UNDERSTAND THAT
ANNUITY PAYMENTS AND OTHER VALUES PROVIDED BY THE CONTRACT APPLIED FOR, WHEN
BASED ON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT ARE VARIABLE AND NOT
GUARANTEED AS TO FIXED DOLLAR AMOUNT.
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Signed in (State) Date Signed Signature of Signature of
Owner/Applicant Co-Owner
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Signature of Signature of Signature of
Annuitant Co-Annuitant Irrevocable Beneficiary
(if different (if different (if designated)
from Owner) from Co-Owner)
Statement of Agent:
A. / / No / / Yes Will this contract replace or change any existing life
insurance or annuity in this or any other company?
If "Yes," please explain under Remarks.
B. / / Plan B (formerly T) (Default as defined in Selling Agreement.)
/ / Plan C (formerly NT)
C. I certify I am authorized and qualified to discuss the Contract herein
applied for.
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Signature Print Full Name Name of Firm
of Agent
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Agent Number Agent Phone Number State License Date of
ID Number Prospectus
* Unless subsequently changed in accordance with terms of Contract issued.
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Initial next to VENTURE service option(s) you wish to elect. (Service options
operate exclusive of one another.)
/ / Owner MUST initial here to elect this option.
Telephone Transfer Authorization
I authorize the Company to act on transfer instructions given by telephone from
any person who can furnish proper identification. Neither the Company nor any
person authorized by the Company will be responsible for any claim, loss,
liability or expense in connection with a telephone transfer if the Company or
such other person acted on telephone transfer instructions in good faith in
reliance on this authorization.
/ / Owner MUST initial here to elect this option.
Telephone Withdrawal Authorization
I authorize the Company to act on withdrawal instructions given from any person
who can furnish proper identification by telephone. Neither the Company nor any
person authorized by the Company will be responsible for any claim, loss,
liability or expense in connection with a telephone withdrawal if the Company
or such other person acted on telephone withdrawal instructions in good faith
in reliance on this authorization. The minimum withdrawal amount is $1,000.
Withdrawal instructions may authorize Partial Withdrawals of up to $50,000.00
per account. (Full withdrawals are not permitted by telephone.) The check may
only be payable to the owner of record (who must be individual and may be
mailed only to the address of record. The Company will not allow telephone
withdrawals for the following accounts: a) An account on which the address has
been changed in the last 30 days, b) Accounts over which a person has Power of
Attorney, c) 403(b) accounts for which the owner is under 59 1/2, d) Custodial
accounts, and e) Accounts with Market Timers as owners.
/ / Owner MUST initial here to elect this option.
Automatic Rebalancing
If marked, the policyholder's contract value, excluding amounts in the fixed
account investment options, will be automatically rebalanced to maintain the
rebalancing percentage levels in the variable portfolios based on the current
total value of the eligible portfolios on the day of rebalancing.
You may change the rebalancing percentages or terminate your participation in
the program by providing the Company with a completed Automatic Rebalancing
Authorization form or by providing instructions via telephone to an authorized
Company representative prior to the day the rebalancing will occur.
If a policyholder elects to participate in Automatic Rebalancing, the total
value of the variable portfolios must be included in the program. Therefore,
fund exchanges and subsequent payments received and applied to portfolios in
percentages different from the current rebalancing allocation will be
rebalanced at the next date of rebalancing unless the subsequent payments are
allocated to the fixed account investment options.
Rebalancing will occur on the 25th of the month (or next business day), please
indicate frequency. If no frequency is indicated, then Automatic Rebalancing
will occur Quarterly:
/ / Quarterly / / Semi-Annually (June & December) / / Annually (December)
Rebalancing percentages as indicated by variable Investment Allocations elected
on the first page of the application, unless subsequently changed.
/ / Owner MUST initial here to elect this option.
Dollar Cost Averaging* (Minimum Payment $6,000)
I authorize the Company to transfer an amount (minimum $100) each month as
indicated below. Transfers are available from all variable and the one-year
fixed investment options. A maximum of 10% from the one-year fixed investment
option may be transferred monthly (10% maximum waived for promotional DCA
programs). Please make first transfer on --/--/-- (mm/dd/yy).
START DATE: ----------- (Indicate day of month excluding 29th, 30th, or 31st.)
If application is received AFTER the requested start date, transfers will
commence on the requested day of the following month. If no start date is
indicated or the selected start date falls on a weekend or holiday, transfers
will commence on the next available business day.
Length of Transfer Period: / / Indefinitely (or as long as all source funds
have balances.)
/ / ----- Months
Source Fund Monthly Amount
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Destination Fund Monthly Amount to Destination Fund
---------------------------------- $-----------------------
---------------------------------- $-----------------------
---------------------------------- $-----------------------
*Unless subsequently changed in accordance with terms of Contract issued.
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Initial next to VENTURE service option(s) you wish to elect. (Service options
operate exclusive of one another.)
/ / Owner MUST initial here to elect this option. Income Plan*
(Minimum Payment $12,000)
I authorize withdrawals (minimum $100) from my Contract Value to commence as
indicated below. A maximum of 10% of payments may be withdrawn annually. When
utilizing the Income Plan, I agree that if any debit/transfer is erroneously
received by the bank indicated on the enclosed voided check, or is not honored
upon presentation, any accumulation units may be canceled, and agree to hold the
Company harmless from any loss due to such electronic debits/transfers.
$_______ prorata from active variable portfolios OR
From: _________________________ $__________________
From: _________________________ $__________________
From: _________________________ $__________________
From: _________________________ $__________________
From: _________________________ $__________________
INDICATE FREQUENCY: / / Monthly or / / Quarterly (January, April, July and
October)
Day of Withdrawal: / / 1st / / 7th / / 16th or / / 26th
FEDERAL TAX INFORMATION (If no selection is made, the Company will NOT withhold
taxes.)
CHOOSE ONE: / / Do not withhold Federal Income Taxes
/ / Withhold the 10% minimum (20% for 403(b) TSA accounts)
for Federal Income Tax
/ / Withhold $______________
[ ] I wish to utilize Electronic Funds Transfer in the processing of my
Income Plan (may take 20 business days).
A VOIDED CHECK MUST BE ATTACHED.
Or, if different from owner, make check payable to:
________________________________________________________________________________
First Middle Last
________________________________________________________________________________
Street City State Zip
(Allow 7 business days for receipt of check.)
/ / Owner MUST initial here to elect this option. Guarantee Plus Program
(Minimum Payment $5,000)
The Company will allocate a portion of the payment with this application to the
7-year Fixed Account, such that, at the end of the 7-year period, the account
will have grown to an amount at least equal to the total payment. The remaining
balance will be allocated proportionately according to the investment selections
on the application, which should total 100% excluding the amount allocated to
the 7-year Fixed Account.
THIS OPTION IS NOT AVAILABLE IN FL, MD AND OR.
/ / Owner MUST initial here to elect this option. Check Plus-Automatic Purchase*
I authorize the Company to collect $______ (minimum $30) starting the month of
__________ by initiating electronic debit entries to my bank account with the
following frequency: / / Monthly: / / 5th or / / 20th / / Quarterly (20th of
January, April, July and October). When utilizing Check Plus, I agree that if
any debit/transfer is erroneously received by the bank indicated on the enclosed
voided check, or is not honored upon presentation, any accumulation units may be
canceled, and agree to hold the Company harmless from any loss due to such
electronic debits/transfers. (A VOIDED CHECK MUST BE ATTACHED.)
*Unless subsequently changed in accordance with terms of Contract issued.
