Exhibit 99.5(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. If chosen do not complete allocation percentages below.
ASSET ALLOCATION MODEL Asset Allocation Models are rebalanced quarterly.
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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 _____%
INVESCO VIF Technology _____% Dreyfus VIF Appreciation _____% MFS VIT Investors Trust _____%
AIM V.I. Capital Appreciation _____% Dreyfus Socially Respo. 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 _____% Xxxxx Xxx Growth Stock _____%
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] 5/04
