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...Llac Variable Account • April 30th, 2004
1. ISSUANCE 3 A. Applications and Policy Issuance 3 B. Effective Date of Contract and Interest Calculation 3 C. Contract Amendments 4Llac Variable Account • April 30th, 2004
