Exhibit 99.5(a)
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON [contract#####]
APPLICATION FOR MODIFIED SINGLE PAYMENT VARIABLE LIFE INSURANCE AND CONTRACT
INFORMATION
1. Plan: / / Single Life
/ / Single Life W/Last Survivor Benefit 2. Initial Payment $______________
Agreement
Additional Agreements
______________________________________________ Initial Death Benefit $______________
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)
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3A. 4A.
Birth Date ________________ Age ______ Birth Date ________________ Age ______
Place of Birth ________________ / / Male / / Female Place of Birth ________________ / / Male / / Female
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Social Security Occupation Social Security 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) % %
PAYMENT ALLOCATION Allocations must total 100%. The minimum percentage allocation is [5%] and must be in whole numbers.
If chosen do not complete allocation percentages below.
8.
ASSET ALLOCATION MODEL _______________________ Asset Allocation Models are rebalanced quarterly.
8A. FIXED ACCOUNT _____% 8B. 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 INVESCO VIF Technology _____ % 470 Dreyfus VIF Appreciation ____ % 560 MFS VIT Investors Trust ____ %
380 AIM V.I. Capital 471 Dreyfus Socially
Appreciation _____ % Responsible Growth ____ % 570 MFS VIT Research ____ %
110 Colonial Strategic Income 472 Dreyfus IP Emerging 571 MFS VIT Capital
_____ % Leaders ____ % 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 Xxxxx Xxx Growth Stock ____ %
670 Franklin Large Cap Growth ____ % Other ____ %
SPV-9890-APP [copy 1 to Liberty Life] [copy 2 to agent] [copy 3 to client] 5/04
[contract#####]
UNDERWRITING INFORMATION Please answer Yes or No, circle all that apply and
provide details as requested.
INSURED A INSURED B
9. Has the insured been: Yes No Yes No
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, paralysis, multiple sclerosis or
other nervous system disorder, liver disease, Acquired Immunodeficiency Syndrome / / / / / / / /
(AIDS), alcohol or drug abuse?
D. Turned down, cancelled or refused renewal of life or health insurance? / / / / / / / /
INSURED A INSURED B
10. Has the insured been: Yes No Yes No
A. Diagnosed with or treated within the last 10 years for: heart disease or arrhythmia,
blood pressure treated with medication, vascular or circulatory disease, emphysema
or other chronic lung or respiratory disorder (COPD), cancer, diabetes, Crohn's
disease, ulcerative colitis, epilepsy, anemia or other disease or disorder of the
blood or immune system, or been advised to have a diagnostic test or surgery which
has not been performed (excluding HIV tests or dental work)? / / / / / / / /
B. Unable to work or perform regular activities for more than 7 consecutive days within
the past 12 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? / / / / / / / /
Insured A Insured B CLASS DETERMINATION INSURED A INSURED B
Height ___________ ____________ Standard / / Standard / /
Weight ___________ ____________ Rated / / Rated / /
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. Attach an additional sheet of paper for additional space, if necessary.
Please check the box if an additional sheetis attached / /.
Ques. NAME OF PROPOSED DETAILS/CONDITIONS/ ONSET RECOVERY NAME & ADDRESS OF PHYSICIANS & HOSPITALS
No. INSURED COMPLICATIONS MO/YR MO/YR
SUITABILITY
PLEASE READ CAREFULLY Yes No
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] 5/04
[contract#####]
SPECIAL REQUESTS Yes No
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 and
mental health.
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.
I understand that the receipt of an accelerated death benefit may affect
eligibility for public assistance programs and may be taxable. I understand
there is a one-time administration fee not to exceed $100 when I submit a claim
to accelerate the benefit. I understand the amount of accelerated death benefit
elected will be discounted because it is an early payment.
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 Question 6 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 ___________ -------------------------------------------
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] 5/04
