TYPE OF CONTRACT: [QUALIFIED] CONTRACT DATE: [8/1/2009] INITIAL PAYMENT: [$100,000.00] CONTRACT NUMBER: [000000005] OWNER: [JOHN X. SMITH] GOVERNING LAW: [YS] ANNUITANT: [JOHN X. SMITH] ANNUITANT'S AGE [55] [CO-OWNER:] [ ]John Hancock Life Insurance Co (Usa) Separate Account H • May 15th, 2009
Company FiledMay 15th, 2009