Exhibit 99.B.5(b)
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON
VARIABLE LIFE INSURANCE SUPPLEMENTAL APPLICATION
1. PLAN / / Single Premium Single Life Variable Life Insurance / / Single Premium Last Survivor Variable Benefit Agreement
/ / Flexible Premium Single Life Variable Life Insurance / / Other__________________________________________________
2. INSURED A First MI Last Date of Birth Social Security Number
/ / - -
3. INSURED B First MI Last Date of Birth Social Security Number
/ / - -
PAYMENT ALLOCATION Allocations must total 100%. The minimum percentage allocation is [5%] and must be in whole numbers.
4. ASSET ALLOCATION MODEL ______________________________________________ If chosen do not complete allocation percentages below.
Asset Allocation Models are rebalanced quarterly.
4A. FIXED ACCOUNT _____%
4B. SUB-ACCOUNTS Please make no more than [10] selections.
AIM V.I. Government Securities _______% Dreyfus IP Technology Growth _______% MFS VIT High Income _______%
AIM V.I. International Growth _______% Dreyfus Stock Index _______% MFS VIT Utilities _______%
AIM V.I. Technology _______% Dreyfus VIF Appreciation _______% MFS VIT Investors Trust _______%
AIM V.I. Capital Appreciation _______% Dreyfus Socially Responsible Growth _______% MFS VIT Research _______%
Colonial Strategic Income _______% Dreyfus IP Emerging Leaders _______% MFS VIT Capital Opportunities _______%
Columbia High Yield _______% Franklin Money Market _______% MFS VIT Emerging Growth _______%
Liberty Growth & Income _______% Franklin Strategic Income _______% Liberty Money Market _______%
Colonial Small Cap Value _______% Xxxxxxxxx Growth _______% Liberty Asset Allocation _______%
Franklin Growth and Income _______% Columbia Large Cap Growth _______%
Franklin Large Cap Growth _______% Other _______%
SPECIAL REQUESTS Yes No
5. Is Dollar Cost Averaging elected? / / / /
6. Is Account Rebalancing elected? (Do not complete if an Asset Allocation Model is used.) / / / /
7. Please indicate if you refuse Telephone Transfer privileges. / /
If you answered Yes to questions 5 or 6, applicable administrative form(s) must be completed and submitted for your elections
to be effective.
SUITABILITY
PLEASE READ CAREFULLY Yes No
8. Did you receive the current prospectus for the life contract applied for? / / / /
9. Do you understand that the contract values including the Death Benefit may increase or decrease,
depending on the investment performance of the sub-accounts? / / / /
10. Do you understand that the contract may lapse only if the surrender value becomes insufficient to cover the
Monthly Deductions? / / / /
11. Do you understand that the initial payment may be held in the Fixed Account until after your Right to Return
period expires? / / / /
12. Do you believe that this contract is consistent with your insurance needs and financial objectives? / / / /
THE AMOUNT AND DURATION OF THE DEATH BENEFIT AND OTHER VALUES PROVIDED BY THIS
CONTRACT ARE BASED ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT, THE
FIXED ACCOUNT EARNINGS AND CONTRACT CHARGES. SEPARATE ACCOUNT VALUES ARE
VARIABLE AND MAY INCREASE OR DECREASE. THESE VALUES ARE NOT GUARANTEED AS TO
FIXED DOLLAR AMOUNT.
I/we, the Owner(s), declare that the statements and answers in this supplemental
application are complete and true to the best of my/our knowledge and belief and
agree that they will become part of any contract of insurance issued by the
Company.
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Signature of Insured A Signature of Insured B
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Signature of Joint Owner Signature of Owner if Other than Insured(s)
Dated at _____________________ on ___________________ --------------------------------------------------
City and State Date Signature of Registered Representative
PLA-98120 [copy 1 to Liberty Life] [copy 2 to agent] [copy 3 to client] 5/05
