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THE MANUFACTURERS LIFE INSURANCE COMPANY OF NORTH AMERICA
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[MANULIFE FINANCIAL LOGO] [VENTURE VANTAGE 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*______________________________________________________
First Middle Last
Address____________________________________________________
Street
___________________________________________________________
City State Zip
Sex [ ] M [ ] F Date of Birth ______/______/______
Month Day Year
Daytime Phone Number: ( ) _______________________________
__/__/__/__/__/__/__/__/__ or __/__/__/__/__/__/__/__/___
Social Security Number Tax ID Number
Client Brokerage Acct. #: _________________________________
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CO-OWNER (Complete if applicable)
Name*______________________________________________________
First Middle Last
Sex [ ] M [ ] F Date of Birth ______/______/______
Month Day Year
Daytime Phone Number: ( ) _______________________________
__/__/__/__/__/__/__/__/__ or __/__/__/__/__/__/__/__/___
Social Security Number Tax ID Number
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ANNUITANT (If different from Owner)
Name*______________________________________________________
First Middle Last
Address____________________________________________________
Street
___________________________________________________________
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*______________________________________________________
First Middle Last
Address____________________________________________________
Street
___________________________________________________________
City State Zip
Sex [ ] M [ ] F Date of Birth ______/______/______
Month Day Year
__/__/__/__/__/__/__/__/__
Social Security Number
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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 $10,000)
Payment Method: [ ] Check [ ] Wire [ ] 1035 Exchange
[ ] Transfer/Rollover [ ] Other _________
______% Manufacturers Adviser Pac Rim Emerging Markets (081)
______% X. Xxxx Price Science & Technology (082)
______% Founders Int'l Small Cap (083)
______% Warburg Pincus Emerging Small Company (084)
______% Pilgrim Xxxxxx Growth (085)
______% Xxxx Xxxxx Small/Mid Cap (086)
______% Xxxx Xxxxx-Xxxxxxx Int'l Stock (087)
______% Founders Worldwide Growth (088)
______% Xxxxxx Xxxxxxx Global Equity (089)
______% Xxxxxxxxx Small Company Value (120)
______% Fidelity Equity (091)
______% Founders Growth (090)
______% Manufacturers Adviser Quant Equity (092)
______% X. Xxxx Price Blue Chip Growth (093)
______% Manufacturers Adviser Real Estate Securities (094)
______% Xxxxxx Xxxxxxxx Value (095)
______% X.X. Xxxxxx Int'l Growth & Income (096)
______% Wellington Management Growth & Income (097)
______% X. Xxxx Price Equity-Income (098)
______% Founders Balanced (099)
______% Fidelity Aggr Asset Alloc (100)
______% Xxxxxx Xxxxxxxx High Yield (101)
______% Fidelity Mod Asset Alloc (102)
______% Fidelity Cons Asset Alloc (103)
______% Salomon Brothers Strategic Bond (104)
______% Oechsle Global Gov't Bond (105)
______% Manufacturers Adviser Capital Growth Bond (106)
______% Wellington Management Inv Quality Bond (107)
______% Salomon Brothers U.S. Gov't Securities (108)
______% Manufacturers Adviser Money Market (109)
LIFESTYLE PORTFOLIOS
______% Cons 280 (110)
______% Bal 640 (112)
______% Aggr 1000 (114)
______% Mod 460 (111)
______% Growth 820 (113)
FIXED ACCOUNT
______% 1 Yr (021/028)(1)
(1) not available in OR.
*Unless subsequently changed in accordance with terms of Contract issued.
1/99
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3. BENEFICIARIES (ENCLOSE SIGNED LETTER IF MORE INFORMATION IS REQUIRED)
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Name*________________________________________________________________ Date of Birth _____/_____/____ __/__/__/__/__/__/__/__/__
First Middle Last Relationship % Month Day Year Social Security Number
Name*________________________________________________________________ Date of Birth _____/_____/____ __/__/__/__/__/__/__/__/__
First Middle Last Relationship % Month Day Year Social Security Number
CONTINGENT BENEFICIARY
Name*________________________________________________________________ Date of Birth _____/_____/____ __/__/__/__/__/__/__/__/__
First Middle Last Relationship Month Day Year Social Security Number
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4. PLAN SPECIFICS (MUST BE COMPLETED)
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TYPE OF PLAN: [ ] Non-Qualified [ ] 1035 Exchange, Cost Basis $______
Qualified [ ] XXX Tax Year ___
[ ] XXX Rollover
[ ] XXX Transfer
[ ] Simple XXX
[ ] SEP XXX
[ ] Xxxx XXX
[ ] Xxxxx (HR-10)
[ ] 403(b) Check if ERISA [ ]
[ ] Money Purchase
[ ] 401(k)
[ ] 457
[ ] 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:
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5. SIGNATURES (ALL PARTICIPANTS MUST SIGN APPLICATION, INCLUDING IRREVOCABLE
BENEFICIARY, IF DESIGNATED.)
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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 OHIO, KENTUCKY, PENNSYLVANIA, NEW MEXICO AND ARKANSAS 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 (i) 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)
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Date Signed
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Signature of Owner/Applicant
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Signature of Co-Owner
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Signature of Annuitant (if different from Owner)
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Signature of Co-Annuitant (if different from Co-Owner)
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Signature of Irrevocable Beneficiary (if designated)
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 T [ ] Plan NT (Default is as defined in Selling Agreement)
C. I certify I am authorized and qualified to discuss the Contract herein
applied for.
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Signature of Agent
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Print Full Name
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Name of Firm
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Agent Number
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Agent Phone Number
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State License ID Number
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Date of Prospectus
*Unless subsequently changed in accordance with terms of Contract issued.
1/99
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INITIAL BELOW EACH VENTURE VANTAGE SERVICE OPTION YOU WISH TO ELECT.
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LETTER OF INTENT (MAY NOT BE AVAILABLE FOR CERTAIN QUALIFIED PLANS. OPTION NOT
AVAILABLE IN OREGON.)
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OWNER PLEASE INITIAL HERE ______
I have satisfied the minimum initial purchase payment requirements and beginning
on the Contract issuance date, I intend to invest over a 13 month period, an
aggregate amount at least equal to:
Check one: [ ] $500,000 [ ] $2,500,000
I agree to the Letter of Intent provisions set forth in the Prospectus. If this
aggregate amount is not fulfilled at the end of the 13 month period, the Company
will recover an amount from the contract on that date. The amount the company
will recover is equal to the greater of: a) The excess Payment Enhancement
defined as the Payment Enhancement applied to the contract less the amount of
Payment Enhancement that would have been applied to the contract absent a Letter
of Intent, or b) The contract value multiplied by the ratio of the excess
Payment Enhancement over total purchase payments applied to the Contract.
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CHECK PLUS-AUTOMATIC PURCHASE*
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OWNER PLEASE INITIAL HERE ______
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. (PLEASE ATTACH A VOIDED CHECK/WITHDRAWAL SLIP.)
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DOLLAR COST AVERAGING* (MINIMUM PAYMENT $6,000)
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OWNER PLEASE INITIAL HERE ______
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. Please make first transfer on __ /__ /__
(mm/dd/yy).
SOURCE FUND DESTINATION FUND AMOUNT
_______________________ _________________________________ $___________________
_______________________ _________________________________ $___________________
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INCOME PLAN* (MINIMUM PAYMENT $6,000)
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OWNER PLEASE INITIAL HERE ______
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.
From:__________________________________ $_______________________
From:__________________________________ $_______________________
From:__________________________________ $_______________________
From:__________________________________ $_______________________
From:__________________________________ $_______________________
Please indicate frequency: [ ] Monthly or [ ] Quarterly (January, April,
July and October)
Day of Withdrawal: [ ] 1st [ ] 7th
[ ] 16th or [ ] 26th
Please [ ] Withhold [ ] Do not withhold
Federal Income Taxes
[ ] I wish to utilize Electronic Funds Transfer in the processing of my Income
Plan. PLEASE ATTACH A VOIDED CHECK.
Or, if different from owner, make check payable to:
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First Middle Last
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Street City State Zip
(Please allow 7 business days for receipt of check.)
*Unless subsequently changed in accordance with terms of Contract issued.
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INITIAL BELOW EACH VENTURE VANTAGE SERVICE OPTION YOU WISH TO ELECT.
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TELEPHONE TRANSFER AUTHORIZATION
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OWNER PLEASE INITIAL HERE ______
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.
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TELEPHONE WITHDRAWAL AUTHORIZATION
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OWNER PLEASE INITIAL HERE ______
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.
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AUTOMATIC REBALANCING
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OWNER PLEASE INITIAL HERE ______
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 as selected below,
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,
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:
[ ] Quarterly [ ] Semi-Annually (June & December) [ ] Annually (December)
ASSET ALLOCATIONS (must total 100%):
______% Manufacturers Adviser Pac Rim Emerging Markets (081)
______% X. Xxxx Price Science & Technology (082)
______% Founders Int'l Small Cap (083)
______% Warburg Pincus Emerging Small Company (084)
______% Pilgrim Xxxxxx Growth (085)
______% Xxxx Xxxxx Small/Mid Cap (086)
______% Xxxx Xxxxx-Xxxxxxx Int'l Stock (087)
______% Founders Worldwide Growth (088)
______% Xxxxxx Xxxxxxx Global Equity (089)
______% Xxxxxxxxx Small Company Value (120)
______% Fidelity Equity (091)
______% Founders Growth (090)
______% Manufacturers Adviser Quant Equity (092)
______% X. Xxxx Price Blue Chip Growth (093)
______% Manufacturers Adviser Real Estate Securities (094)
______% Xxxxxx Xxxxxxxx Value (095)
______% X.X. Xxxxxx Int'l Growth & Income (096)
______% Wellington Management Growth & Income (097)
______% X. Xxxx Price Equity-Income (098)
______% Founders Balanced (099)
______% Fidelity Aggr Asset Alloc (100)
______% Xxxxxx Xxxxxxxx High Yield (101)
______% Fidelity Mod Asset Alloc (102)
______% Fidelity Cons Asset Alloc (103)
______% Salomon Brothers Strategic Bond (104)
______% Oechsle Global Gov't Bond (105)
______% Manufacturers Adviser Capital Growth Bond (106)
______% Wellington Management Inv Quality Bond (107)
______% Salomon Brothers U.S. Gov't Securities (108)
______% Manufacturers Adviser Money Market (109)
Lifestyle Portfolios
______% Cons 280 (110)
______% Bal 640 (112)
______% Aggr 1000 (114)
______% Mod 460 (111)
______% Growth 820 (113)
*Unless subsequently changed in accordance with terms of Contract issued.
