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THE MANUFACTURERS LIFE INSURANCE COMPANY OF NORTH AMERICA
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MANULIFE FINANCIAL VENTURE
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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 chack 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
__________________________ 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
Sex [ ]M [ ]F Date of Birth ________________
Month Day Year
Daytime Phone Number: ( )____________________
__________________________
Social Security Number
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Group Holder (NJ, PA, SC, TX, WA Only)
In certain states, certificates are issued under a Master Group contract.
Name____________________________________ Venture Trust______________________
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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 $2,000 qualified; $5,000 non-qualified):
Payment Method: [ ] Check [ ] Wire [ ] 1035 Exchange
[ ] Transfer/Rollover [ ] Other _________
____ % Manufacturers Adviser Pac Rim Emerging Mkts (008)
____ % X. Xxxx Price Science & Technology (016)
____ % Founders Int'l Small Cap (006)
____ % Warburg Pincus Emerging Small Company(020)
____ % Pilgrim Xxxxxx Growth (022)
____ % Xxxx Xxxxx Small/Mid Cap (011)
____ % Xxxx Xxxxx-Xxxxxxx Int'l Stock (024)
____ % Founders Worldwide Growth (026)
____ % Xxxxxx Xxxxxxx Global Equity (009)
____ % Xxxxxxxxx Small Company Value (119)
____ % Fidelity Equity (001)
____ % Founders Growth (005)
____ % Manufacturers Adviser Quant Equity (065)
____ % X. Xxxx Price Blue Chip Growth (012)
____ % Manufacturers Adviser Real Estate Securities (068)
____ % Xxxxxx Xxxxxxxx Value (066)
____ % X.X. Xxxxxx Int'l Growth & Income (013)
____ % Wellington Management Growth & Income (017)
____ % X. Xxxx Price Equity-Income (007)
____ % Founders Balanced (071)
____ % Fidelity Aggr Asset Alloc (004)
____ % Xxxxxx Xxxxxxxx High Yield (076)
____ % Fidelity Mod Asset Alloc (003)
____ % Fidelity Cons Asset Alloc (002)
____ % Salomon Brothers Strategic Bond (015)
____ % Oechsle Global Gov't Bond (010)
____ % Manufacturers Adviser Capital Growth Bond (080)
____ % Wellington Management Inv Quality Bond (018)
____ % Salomon Brothers U.S. Gov't Securities (014)
____ % Manufacturers Adviser Money Market (019)
Lifestyle Portfolios
____ % Cons 280 (179) ____ % Mod 460 (180)
____ % Bal 640 (181) ____ % Growth 820 (182)
____ % Aggr 1000 (183)
Fixed Accounts
____ % 1 Yr (021/028) ____ % 3 Yr (023/029)
____ % 5 Yr (025)(1) ____ % 6 Yr (030)(2)
____ % 7 Yr (027)(1)
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(1) not available in MD, OR.
(2) available only in MD, OR.
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VENTURE.APP.009.98 *Unless subsequently changed in accordance 12/98
with terms of Contract issued.
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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. RIDERS (Optional)
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[ ] No [ ] Yes GRIP (GUARANTEED RETIREMENT INCOME PROGRAM) Not available in
all states.
(Irrevocable) Do you choose to elect the Guaranteed Retirement Income
Program (GRIP) benefit?
If "Yes," there is an additional 0.25% annual fee, charged
on each contract anniversary. See prospectus for details.
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5. PLAN SPECIFICS (Must be completed)
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Type of Plan: [ ] Non-Qualified (minimum $5,000) [ ]1035 Exchange, Cost Basis $_______
Qualified [ ] XXX Tax Year __ [ ] Simple XXX [ ] Xxxxx (HR-10) [ ] 401(k) [ ] Profit Sharing
(minimum [ ] XXX Rollover [ ] SEP XXX [ ] 403(b) Check if ERISA [ ] 457 [ ] Other____
$2,000) [ ] XXX Transfer [ ] Xxxx XXX [ ] Money Purchase [ ] Defined Benefit
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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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6. 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: (1) 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 representa-tions 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.
_______________________________________________________________________________
Signed in (State) Date Signed Signature of Owner/Applicant Signature of Co-Owner
_______________________________________________________________________________
Signature of Annuitant Signature of Co-Annuitant Signature of
(if different from Owner) (if different from Co-Owner) 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.
_______________________________________________________________________________
Signature of Agent Print Full Name Name of Firm
_______________________________________________________________________________
Agent Number Agent Phone Number State License ID Number Date of Prospectus
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VENTURE.APP.009.98 *Unless subsequently changed in accordance 12/98
with terms of Contract issued.
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Initial below each VENTURE service option you wish to elect.
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GUARANTEE PLUS PROGRAM (MINIMUM PAYMENT $5,000)
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OWNER PLEASE INITIAL HERE _________________.
The Company will allocate a portion of the payment with this application to the
7-year Fixed Account, (6 years in some states) such that, at the end of the
7-year period, the account will have grown to an amount at least equal to the
total payment. The remaining balance will be allocated proportionately
according to the investment selections on the application, which should total
100% excluding the amount allocated to the 7-year Fixed Account.
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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 vari-able 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 $12,,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 indicat-ed 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:
_______________________________________________________________________________
First Middle Last
_______________________________________________________________________________
Street City State Zip
(Please allow 7 business days for receipt of check.)
________________________________________________________________________________
VENTURE.APP.009.98 *Unless subsequently changed in accordance 12/98
with terms of Contract issued.
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Initial below each VENTURE 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 eligi-ble 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 Mkts (008)
____ % X. Xxxx Price Science & Technology (016)
____ % Founders Int'l Small Cap (006)
____ % Warburg Pincus Emerging Small Company (020)
____ % Pilgrim Xxxxxx Growth (022)
____ % Xxxx Xxxxx Small/Mid Cap (011)
____ % Xxxx Xxxxx-Xxxxxxx Int'l Stock (024)
____ % Founders Worldwide Growth (026)
____ % Xxxxxx Xxxxxxx Global Equity (009)
____ % Xxxxxxxxx Small Company Value (119)
____ % Fidelity Equity (001)
____ % Founders Growth (005)
____ % Manufacturers Adviser Quant Equity (065)
____ % X. Xxxx Price Blue Chip Growth (012)
____ % Manufacturers Adviser Real Estate Securities (068)
____ % Xxxxxx Xxxxxxxx Value (066)
____ % X.X. Xxxxxx Int'l Growth & Income (013)
____ % Wellington Management Growth & Income (017)
____ % X. Xxxx Price Equity-Income (007)
____ % Founders Balanced (071)
____ % Fidelity Aggr Asset Alloc (004)
____ % Xxxxxx Xxxxxxxx High Yield (076)
____ % Fidelity Mod Asset Alloc (003)
____ % Fidelity Cons Asset Alloc (002)
____ % Salomon Brothers Strategic Bond (015)
____ % Oechsle Global Gov't Bond (010)
____ % Manufacturers Adviser Capital Growth Bond (080)
____ % Wellington Management Inv Quality Bond (018)
____ % Salomon Brothers U.S. Gov't Securities (014)
____ % Manufacturers Adviser Money Market (019)
LIFESTYLE PORTFOLIOS
____ % Cons 280 (179) ____ % Mod 460 (180)
____ % Bal 640 (181) ____ % Growth 820 (182)
____ % Aggr 1000 (183)
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VENTURE.APP.009.98 *Unless subsequently changed in accordance 12/98
with terms of Contract issued.
