Exhibit 99.B(5)(a)
[contract#####]
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON
APPLICATION FOR MODIFIED SINGLE PAYMENT VARIABLE LIFE INSURANCE AND CONTRACT
INFORMATION
1. Plan: / / Single Life 2.
/ / Single Life w/Last Survivor Benefit Agreement Initial Payment $______________
Additional Agreements Initial Death Benefit $______________
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3. INSURED A 4. INSURED B
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First MI Last First MI Last
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Street Street
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City State Zip City State Zip
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Telephone Number (home) (work) Telephone Number (home) (work)
3A. 4A.
Birth Date ________________ Age ______ Birth Date ________________ Age ______
Place of Birth ________________ / / Male / / Female Place of Birth ________________ / / Male / / Female
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Social Security Number Occupation Social Security Number Occupation
5. Will this contract replace any existing life insurance policy or annuity contract in this or any other company?
Yes / / No / / If yes, please list company name and policy/contract number(s).
Company name: ________________________________ Policy/Contract Number ___________________
OWNER(S) (IF OTHER THAN PROPOSED INSURED(S))
6. Name Address
Tax ID/Social Security Number
If payor is other than owner: Payor Address
Name:
BENEFICIARY All designated beneficiaries will be considered primary beneficiaries, sharing equally, unless otherwise
indicated.
7.
RELATIONSHIP PRIMARY CONTINGENT RELATIONSHIP PRIMARY CONTINGENT
NAME (TO INSURED) % % NAME (TO INSURED) % %
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PAYMENT ALLOCATION Allocations must total 100%. The minimum percentage allocation is [5%] and must be in whole numbers.
8. If chosen do not complete allocation percentages below.
ASSET ALLOCATION MODEL ______________________________________ Asset Allocation Models are rebalanced quarterly.
8A. 8B.
FIXED ACCOUNT _____% First Year Fixed Account Guaranteed Interest Rate _______ %
8C. SUB-ACCOUNTS Please make no more than [10] selections.
310 AIM V.I. Govt. Securities ____% 440 Dreyfus IP Tech. Growth ____% 520 MFS VIT High Income ____%
350 AIM V.I. International Growth ____% 460 Dreyfus Stock Index ____% 540 MFS VIT Utilities ____%
370 AIM V.I. Technology ____% 470 Dreyfus VIF Appreciation ____% 560 MFS VIT Investors Trust ____%
380 AIM V.I. Capital Appreciation ____% 471 Dreyfus Socially Responsible Growth ____% 570 MFS VIT Research ____%
110 Colonial Strategic Income ____% 472 Dreyfus IP Emerging Leaders ____% 571 MFS VIT Capital Opportunities ____%
120 Columbia High Yield ____% 600 Franklin Money Market ____% 580 MFS VIT Emerging Growth ____%
160 Liberty Growth & Income ____% 610 Franklin Strategic Income ____% 200 Liberty Money Market ____%
170 Colonial Small Cap Value ____% 650 Xxxxxxxxx Growth ____% 230 Liberty Asset Allocation ____%
660 Franklin Growth & Income ____% 270 Columbia Large Cap Growth ____%
670 Franklin Large Cap Growth ____% Other ____%
SPV-9890-APP [copy 1 to Liberty Life] [copy 2 to agent] [copy 3 to client] 5/05
[contract#####]
UNDERWRITING INFORMATION Please answer Yes or No, circle all that apply and
provide details as requested.
INSURED A INSURED B
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YES NO YES NO
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9. Has the insured been:
A. Hospitalized or surgically treated within the last 2 years for heart disease? / / / / / / / /
B. Treated within the last 5 years for cancer? / / / / / / / /
C. Diagnosed with or treated by a member of the medical profession for: stroke
or other cerebrovascular disease (TIA), diabetes treated with insulin,
kidney disease (not to include bladder or prostate), Alzheimer's disease or
other neurological disorder, liver disease, organ transplant, Acquired
Immunodeficiency Syndrome (AIDS) or AIDS Related Complex (ARC),
alcohol or drug abuse? / / / / / / / /
D. Turned down, cancelled or refused renewal of life or health
insurance? / / / / / / / /
INSURED A INSURED B
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YES NO YES NO
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10. Has the insured been:
A. Diagnosed with or treated within the last 10 years for: heart disease or
arrhythmia, blood pressure treated with medication, vascular or circulatory
disease, fainting spells, emphysema or other chronic lung or respiratory
disorder (COPD), cancer, diabetes, Crohn's disease, regional enteritis,
ulcerative colitis, or chronic gastritis? / / / / / / / /
B. Unable to work or perform regular activities for more than 7 consecutive days
within the past 6 months because of sickness or injury? / / / / / / / /
C. Hospitalized for any reason within the last 6 months? / / / / / / / /
D. Charged an extra rate for life or health insurance? / / / / / / / /
CLASS DETERMINATION INSURED A INSURED B
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STANDARD / / STANDARD / /
CLASS A / / CLASS A / /
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11. Has the Insured used tobacco of any kind within the last 12 months? Yes / / Yes / /
No / / No / /
12. Provide full details here for questions 9 and 10 answered "Yes." Please
include date of onset, any medications taken, treatment received, names of
hospitals and treating physicians.
QUES. NAME OF PROPOSED DETAILS/CONDITIONS/ ONSET RECOVERY
No. INSURED COMPLICATIONS MO/YR MO/YR NAME & ADDRESS OF PHYSICIANS & HOSPITALS
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SUITABILITY
PLEASE READ CAREFULLY YES NO
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13. Did you receive the current prospectus for the life contract applied for? / / / /
14. Do you understand that the contract values including the Death Benefit may
increase or decrease, depending on the investment performance of the
sub-accounts? / / / /
15. Do you understand that the contract may lapse only if the surrender value
becomes insufficient to cover the Monthly Deductions? / / / /
16. Do you understand that the initial payment may be held in the Fixed Account
until after your Right to Return period expires? / / / /
17. Do you believe that this contract is consistent with your insurance needs and
financial objectives? / / / /
AGENT
To the best of your knowledge, will the Bank Name/GA Branch
contract applied for replace any existing life
insurance or annuity in this or any
other company? Yes / / No / /
Agent Name FAX Number Agent License Number
Agent Signature Telephone Number Split Commissions Yes / / No / / _____% to
Name:
SPV-9890-APP [copy 1 to Liberty Life] [copy 2 to agent] [copy 3 to client]
[contract#####]
SPECIAL REQUESTS YES NO
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18. Is Dollar Cost Averaging elected? / / / /
19. Is Asset Rebalancing elected? (Do not complete if an Asset Allocation Model
is used.) / / / /
20. Please indicate if you refuse Telephone Transfer privileges. / /
If you answered Yes to question 18, applicable administrative form(s) must
be completed and submitted for your elections to be effective.
SIGNATURES
AUTHORIZATION TO OBTAIN INFORMATION
I AUTHORIZE any licensed physician, medical practitioner, hospital, clinic,
other medical or medically-related facility, insurance or reinsuring company,
the Medical Information Bureau, Inc. (MIB), consumer reporting agency, employer
or former employer to give Liberty Life Assurance Company of Boston (Liberty),
its employees and reinsurers any information about my: physical or mental
condition, character, general reputation, habits, finances, insurance history;
occupation; and hobbies. I also authorize Liberty to obtain an investigative
consumer report on me. This authorization applies to all types of information,
including but not limited to information regarding HIV infection, AIDS, mental
health and substance abuse.
I AM AWARE that Xxxxxxx will use this information to determine if I am eligible
for insurance or for benefits under an in force policy/contract. I am aware that
Liberty may give this information to: its reinsurers, the MIB; other persons or
entities that perform services related to my application or claim; or as may be
authorized or required by law.
I AGREE that this form shall be valid for 30 months from the date below. I agree
that a copy will be as valid as this original.
I HAVE received the Notice of Information Practices and the notices required by
the Federal Fair Credit Reporting Act and MIB.
LIVING BENEFIT DISCLOSURE ACKNOWLEDGEMENT
I acknowledge that Liberty's Accelerated Death Benefit is available under this
contract and I have read the disclosure pertaining to Liberty's Living Benefit.
SOCIAL SECURITY OR TAX IDENTIFICATION NUMBER (TIN) CERTIFICATION By signing this
application, the named Owner certifies under penalties of perjury that: (1) the
TIN shown on Questions 3 and 4 of this application is correct, and (2) that I am
not subject to backup withholding either because I have not been notified that I
am subject to backup withholding as a result of a failure to report all interest
or dividends, or the Internal Revenue Service has notified me that I am no
longer subject to backup withholding. (if you are subject to backup withholding,
cross out item 2 above).
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.
INSURING AGREEMENT
I/we declare that all statements and answers given in this application are true
and complete to the best of my/our knowledge and belief. I/we also agree that
they will form the basis for, and be a part of, any contract of insurance issued
by the Company. I/we also agree that: No sales representative has the authority
to determine insurability, waive any rights or requirements of the Company, or
make or modify any contract of insurance. No information obtained by any such
person will bind the Company unless set out in writing in a part of the
application.
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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
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City and State Contract Date Signature of Registered Representative
OFFICE USE ONLY
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SPV-9890-APP [copy 1 to Liberty Life] [copy 2 to agent] [copy 3 to client]
