Exhibit 7
Agency No.
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For Company Use Only
No.
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Pension No.
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Part 1 - Application to the New England Mutual Life
Insurance Company for an Annuity
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Name of
Annuitant
(Print name as it should appear in contract)
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Questions below pertain to Annuitant unless otherwise indicated.
1. Type of Annuity (check one in each) a: Deferred or Immediate
b: Variable or Fixed
2. Address (include street and number, city, state and zip code)
a. Residence
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b. Business
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3. Payment Notice Address
Annuitant at 2.a. at 2.b.
Other than Annuitant (give name and address)
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4. Social Security or Employer Identification No.
Annuitant
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First Owner
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5. Birthplace
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(City) (State or Country)
6. Citizen of
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7. Birth Date
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(Month) (Day) (Year)
8. Sex Male Female
9. Marital Status Married Single Widowed Divorced Separated
10. Basis of Annuity Plan
Qualified Pension or Profit Sharing Plan (401(k))
Individual Retirement Annuity Plan ( Rollover)
Government Deferred Compensation Plan
Tax-Sheltered Annuity
Non-Qualified Individual
Other (specify)
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11. Purchase payment mode Single Annual Quarterly Monthly
MSA No. Other (specify)
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12. Amount (Check and complete only one)
Gross payment including
Riders at mode shown in 11 $
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Monthly income to Annuitant $
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13. Maturity Date (if no date is shown, Maturity Date will be Annuitant's
70th birthday)
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(Month) (Day) (Year)
14. Method of payment to Annuitant -- Note: Payment Option to be Life Income,
10 Years Certain, unless otherwise specified
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15. Disability Benefit Rider Yes (Answer a thru d) No
a. Any other negotiations for disability insurance pending or
contemplated? Yes No
(If Yes, explain on back)
b. Any intent to travel or reside outside USA?
(If Yes, explain on back) Yes No
c. Any participation in SCUBA diving, skydiving, hang gliding, or motor
racing within past 3 years, or any intent to participate in these
activities? Yes No
(If Yes, complete Avocation Questionnaire)
d. Occupation (Be explicit)
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16. Any insurance or annuity in this or any other company which has been
or will be replaced as a result of this Application? (If Yes, explain on
back and give name of company) Yes No
APP-528-87 Rev Continued on Reverse Side
2
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Receipt -- Do Not Destroy
Received ______________________________________________________________dollars
in connection with an application to New England Mutual Life Insurance Company
for an annuity
contract on
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Countersigned ___________________ 19 ____
New England Mutual Life Insurance Company
Secretary /s/ Xxxxx X. Xxxxxxxx
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Agent
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17. Beneficiary (include relation to Annuitant)
(1) Primary (2) Secondary
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18. Is Annuitant to own the contract? Yes No
If No, name the Owner (include relation to Annuitant) (Note: A numbered
sequence may be used to name successive Owners)
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19. Dividend Option:
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20. Any special requests
(Attach memo if more space needed)
Home Office Use: Additions and Amendments
21. Amount paid with this Application
$
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22. Second Annuitant (Immediate Joint Annuities Only)
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Name (Print name as it should appear Relation to Annuitant
in contract)
If Application is for a Variable Annuity, answer questions 23 and 24.
23. Account Allocation (whole %)
____% Capital Growth
____% Back Bay Advisors Bond Income
____% Back Bay Advisors Money Market
____% Westpeak Stock Index
____% Back Bay Advisors Managed
____% Xxxxxx Xxxxxx Avanti Growth
____% Westpeak Value Growth
4
____% Fidelity VIP Equity-Income
____% Fidelity VIP Overseas
____% Xxxxxx Xxxxxx Small Cap
____% Salomon Brothers U.S. Government
____% Xxxxxx Xxxxxx Balanced
____% Xxxxx Equity Growth
____% CS First Boston Strategic Equity Opportunities
____% Draycott International Equity
____% Venture Value
____% Salomon Brothers Strategic Bond Opportunities
____% Fixed Account
(Minimum 10% in each selected account.)
24. Suitability Statement by Applicant
a. Did you receive the prospectus? Yes No
(If Yes, give date of prospectus ____________)
b. Do you understand that the contract value and annuity payments when
based on the investment experience of a separate investment account may
increase or decrease depending on the contract's investment return?
Yes No
c. Do you believe that this contract will meet your financial objectives?
Yes No
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General. To the best of my knowledge and belief, the answers recorded are true
and complete. In those states where written consent is required by law, my
agreement in writing is required to any entry made by the Company in "Additions
and Amendments" as to: (a) age; or (b) type of annuity; or (c) riders; or (d)
amounts; or (e) rate class.
When the Contract Takes Effect. The contract will take effect as of the latest
of: (a) the date of this Application, (b) the date of the first purchase payment
and the first premium for any riders are paid and (c) any date of issue that is
requested; provided that this Application can be approved by the Company as
submitted and with respect to any riders which involve an insurance risk that at
the time of payment there has been a change in insurability as represented in
this Application since the date of the Application.
Signed at (City and State)________________________ Date ______________ 19____
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Agent Annuitant Applicant if other than
Annuitant
Accepted by the Company at the Home Office: _____________ Date ________________
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