Document:

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John Hancock(R)    Life Insurance Company

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WAIVER OF WITHDRAWAL CHARGE ENDORSEMENT
WAIVER OF WITHDRAWAL CHARGE UPON OCCURRENCE OF TRIGGERING EVENTS
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We agree to waive any applicable Withdrawal Charge prior to the date annuity
payments have commenced if 1) beginning at least 30 days after the Effective
Date a Triggering Event occurs and 2) the Covered Person's attained age is less
than 80 on the Effective Date of the certificate.

Triggering Events

Triggering Events are:

1.   A Covered Person being diagnosed with a first occurrence of any Covered
     Condition, subject to the Pre-existing Condition Limitation; and

2.   A Covered Person's confinement in a Nursing Home.

For 2. to be a Triggering Event, the following conditions must be met:

          a.   a Covered Person was not confined to a Nursing Home within two
               years prior to the Effective Date of the certificate.

          b.   a Covered Person's confinement is for at least 90 consecutive
               days;

          c.   a Covered Person is receiving Nursing Care;

          d.   such Nursing Care is based on a Physician's plan in accordance
               with accepted standards of medical practice, and is Medically
               Necessary;

          e.   such Nursing Care is needed because of a Covered Person's
               inability to perform at least two of the Activities of Daily
               Living without Human Assistance because of either Physical
               Impairment or Cognitive Impairment; and

          f.   such Nursing Care is received while the certificate is in force,
               and is not assigned.

Definitions

"Activities of Daily Living" means the following activities:

 .    Bathing, which means washing oneself by sponge bath; or in either a tub or
     shower, including the task of getting into or out of the tub or shower.

 .    Continence, which means the ability to maintain control of bowel and
     bladder functions; and when unable to maintain control of bowel or bladder
     functions, the ability to perform associated personal hygiene (including
     caring for catheter or colostomy bag).

 .    Dressing, which means putting on and taking off all items of clothing and
     any necessary braces, fasteners, or artificial limbs.

 .    Eating, which means feeding oneself by getting food into the body from a
     receptacle (such as a plate, cup, or table) or by feeding tube or
     intravenously. Eating does not include preparing a meal.

 .    Toileting, which means getting to and from the toilet, getting on and off
     the toilet, and performing associated personal hygiene.

 .    Transferring, which means moving into or out of a bed, chair, or
     wheelchair. Transferring does not include the task of getting into or out
     of the tub or shower.
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"Cancer" means the manifestation of a malignant tumor (a tumor which is not
encapsulated and has properties to infiltrate and cause metastases) including
leukemia and Hodgkin's Disease other than Stage 1. The diagnosis must be
supported by histological evidence of malignancy. Specifically excluded from the
definition of cancer are all skin cancers except malignant melanomas, Stage 1
Hodgkin's Disease, Stage A prostate cancer, all tumors which are histologically
described as pre-malignant, and carcinoma-in-situ.

"Cognitive Impairment" means a deficiency in a person's short-term or long-term
memory; orientation as to person, place, and time; deductive or abstract
reasoning; or judgment as it relates to safety awareness.

"Covered Condition" means, as defined herein, cancer, heart attack, organ
transplant, renal failure, or stroke.

"Covered Person" means the Certificate Owner and the Certificate Owner's Spouse.
"Covered Person" will mean the Annuitant and the Annuitant's Spouse if the
certificate is owned by a Trust.

"First occurrence" means the first time a Covered Person is diagnosed by a
Physician as having a Covered Condition. We reserve the right to confirm the
diagnosis with a Physician of our election and at our expense.

"Heart attack" means the death of a portion of heart muscle (myocardium)
resulting from a blockage of the coronary arteries. Diagnosis is based on three
criteria being present: 1) a history of typical prolonged chest pain; 2) new EKG
changes; and 3) elevation of cardiac enzymes above standard laboratory levels of
normal.

"Human Assistance" means physical, hands on, assistance in the case of Physical
Impairment or verbal direction or supervision in the case of a Cognitive
Impairment, which helps another person to perform Activities of Daily Living.

"Medically Necessary" means appropriate and consistent with the diagnosis in
accord with accepted standards of practice, and which could not have been
omitted without adversely affecting the individual's condition.

"Nursing Care" means skilled or intermediate care provided by one or more of the
following health care professionals: registered nurse, licensed vocational
nurse, licensed practical nurse, physical therapist, occupational therapist,
speech therapist, respiratory therapist, medical social worker, or registered
dietitian.

"Nursing Home" means a facility which meets all of the following requirements:

 .    it is licensed and operated to provide Nursing Care for a charge (including
     room and board), according to the laws of the jurisdiction in which it is
     located;

 .    has services performed by or under the continual, direct, and immediate
     supervision of a registered nurse, licensed practical nurse, or licensed
     vocational nurse, on-site twenty-four (24) hours per day.

A Nursing Home may be a freestanding facility or it may be a distinct part of a
facility, including a ward, wing, or swing-bed of a hospital or other facility.

Nursing Home does not mean:

 .    a hospital or clinic;

 .    a rehabilitation hospital or facility;

 .    an assisted care living facility;

 .    a rest home (a home for the aged or a retirement home) which does not, as
     its primary function, provide custodial care;

 .    your primary place of residence, including your living quarters in a
     continuing care retirement community or similar entity;

 .    a facility for the treatment of alcoholism, drug addiction, or mental
     illness.
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"Organ transplant" means the actual undergoing of transplantation of heart,
lung, liver or bone marrow, but not as the donor.

"Physical Impairment" means a loss of physical functioning which interferes with
a person's ability to perform the Activities of Daily Living. A person with a
physical impairment would require hands-on Human Assistance in order to perform
the Activities of Daily Living.

"Physician" is a licensed medical doctor (MD) or a licensed doctor of osteopathy
(DO) practicing within the scope of his or her license issued by the
jurisdiction in which the services are rendered. Physician does not include a
Covered Person, a Covered Person's spouse, children, parents, grandparents,
grandchildren, siblings, or in-laws.

"Pre-existing condition" means the existence of symptoms which would cause an
ordinarily prudent person to seek medical diagnosis, care, and treatment within
one year before the Effective Date of this certificate or a condition for which
medical consultation, advice, or treatment was recommended by or received from
or sought from a Physician during the two years immediately preceding the
Effective Date of the certificate.

"Renal failure" means end stage renal failure representing as chronic
irreversible failure of both kidneys to function, as a result of which regular
renal dialysis is instituted or renal transplantation is carried out.

"Stroke" means a cerebrovascular accident or incident producing neurological
impairment and resulting in paralysis or other measurable objective neurological
deficit persisting for at least 30 days. Specifically excluded from the
definition of stroke are Transient Ischemic Attacks and attacks of
Vertebrobasilar Ischemia.

Pre-Existing Condition Limitation

We will not waive any Withdrawal Charge for a diagnosis of a first occurrence of
a Covered Condition during the first two years after the Effective Date of the
certificate if it results from a Pre-existing Condition, as defined herein.

Benefit Procedure

A written request for a withdrawal and adequate proof of a Triggering Event must
be received by us no later than 90 days, or as soon thereafter as reasonably
possible, from the date of diagnosis of a first occurrence of a Covered
Condition or from the date of discharge from a Nursing Home Facility.

Signed for the Company at Boston, Massachusetts.

                                                    /s/ Barry J. Rubenstein

                                                    Secretary<PAGE>

                                          Modified Guarantee Annuity Application
                        Application to John Hancock Life Insurance Company for a
                                             Deferred Modified Guarantee Annuity
     John Hancock (R)

Complete this application and mail to:                           Overnight Mail:
John Hancock, Annuity New Business,          John Hancock, Annuity New Business,
1 John Hancock Way, Suite 1500,           529 Main Street, Charlestown, MA 02129
Boston, MA  02217-1500

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<S>                                                                       <C>
 For help with this application or for more information, please contact us at [1-800-824-0335]
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1 Who is the Participant?
Name                                                                      Male     Female    Social Security # or Tax I.D. #
                                                                          [_]        [_]
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Street Address                                                            City                      State             Zip

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Home Telephone                                     Business Telephone                               Date of Birth

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2 Who is the Joint Participant?  (Please complete if there is a Joint Participant.)
Name                                                                      Male     Female    Social Security # or Tax I.D. #
                                                                          [_]        [_]
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Street Address                                                            City                      State             Zip

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Home Telephone                                     Business Telephone                               Date of Birth

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3 Who is the Proposed Annuitant?  (Please complete if the Proposed Annuitant is not the Participant)
Name                                                                      Male     Female    Social Security # or Tax I.D. #
                                                                          [_]        [_]
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Street Address                                                            City                      State             Zip

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Home Telephone                                     Business Telephone                               Date of Birth

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4 Who will be the Beneficiary(ies) of the Certificate?
PRIMARY:

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Name (First, Middle, Last)                Address (Street, City, State, Zip Code)           Relationship to Annuitant % of Proceeds
PRIMARY:

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Name (First, Middle, Last)                Address (Street, City, State, Zip Code)           Relationship to Annuitant % of Proceeds
CONTINGENT:

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Name (First, Middle, Last)                Address (Street, City, State, Zip Code)           Relationship to Annuitant % of Proceeds
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                              If no Beneficiary(ies) are listed then the Beneficiary will be the Annuitants estate.
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5 Please send statements and notices to the following:
[_] Annuitant                                         [_] Participant                       [_] Other*
*If Other, please indicate name and address:
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6 What type of Annuity are you Purchasing?  (Please complete the Special Forms Required for IRAs and 1035 Exchanges)
[_] Non Qualified          [_] Direct Transfer        [_] Roth IRA                          [_] SEP IRA
[_] SIMPLE IRA             [_] IRA Rollover           [_] 1035(a) Tax Free Exchange
[_] If Qualified Plan, please indicate tax year: _______________
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<S>                                                   <C>                               <C>
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7   What is the Date of Maturity (Annuity Commencement Date)?
[_] 95/th/ Birthday                                     [_] 90/th/ Birthday                 [_] Other _________(maximum age is 95)
               If Date of Maturity is not elected, the Date of Maturity will be the Annuitant's 95/th/ birthday.
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8 Method of Payment                      (Special tax rules apply to IRA contributions.)
Payment:
The payment of $____________________ will be paid by:
[_] Check payable to John Hancock Life Insurance Company                                   [_] Wire Transfer

[_] Other
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9 What would you like your Initial Guarantee Period to be?

All guarantee periods are subject to availability.  Please select Guarantee Period(s) below and the percent of Initial Premium
 you would like allocated to each Guarantee Period selected.  Percentages must be whole and equal 100%.
       Interest Rate:  Percent of Initial Premium                Interest Rate:  Percent of Initial Premium
[_] 1 Year:   __________  _______________                        [_] 6 Years:   __________  _______________
[_] 2 Years:  __________  _______________                        [ ] 7 Years:   __________  _______________
[_] 3 Years:  __________  _______________                        [_] 8 Years:   __________  _______________
[_] 4 Years:  __________  _______________                        [_] 9 Years:   __________  _______________
[_] 5 Years:  __________  _______________                        [_] 10 Years:  __________  _______________
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10 What is the Effective Date of this Certificate?
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EFFECTIVE DATE:_______/_______/_______
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11 What riders would you like to elect with this annuity?
(only available at time of issue)                                         Age, other restrictions, and other limitations may apply.
       [_] Waiver of Withdrawal Charges due to Nursing Home Confinement/Critical Illness
       [_] Base Certificate Enhancement Rider   (Minimum premium is 25,000 if this Rider is elected)
           This Rider is not available if Annuitant has received Nursing Home Care, Home         Health Care, Hospice Care,
           Respite Care,or Adult Day Care within one year preceding the Effective Date.
       [_] Other _________________________
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12 Will this annuity replace or change any existing annuity or life insurance?
[_] Yes [_] No   If yes, please provide the information below as well as cost basis information
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Company Name                                Certificate Type          Certificate #            Cost Basis
                                                                                               $______________
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13 Special Requests

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14 Please Read Carefully and Sign Below
The following applies to each of the undersigned: To the best of my knowledge and belief, all statements and answers in this
application are true and complete. I (we) acknowledge that John Hancock Life Insurance Company will not be liable for any loss
in acting on any written or telephone instructions that are reasonably believed to be authentic. The annuity certificate will
take effect as of its Effective Date if the Annuitant is living on that date and the required minimum premium has been made. Any
check tendered is received subject to collection only. I (we) understand that the Annuity will be subject to a market value
adjustment that may increase or decrease the Certificate Value if surrendered during a guarantee period. I (we) believe that the
certificate will help me meet my/our financial objectives. If this annuity is for a corporation, business organization, or
trust, I/we represent that the individual(s) signing below has/have the proper authority to enter into this annuity.

      Signature of Participant/Applicant:                                        Date:
     ___________________________________________________________________     _______________________________
      Signature of Joint Participant (if Applicable):                            City, State:

     ___________________________________________________________________     _______________________________
      Signature of Annuitant (if other than Participant):

     ___________________________________________________________________
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For Representative(s) Use Only

Agent:  Do you have any reason to believe that any existing life insurance or annuity has been surrendered, withdrawn from, loaned
        against, changed or otherwise reduced in value or replaced in connection with this transaction assuming the annuity applied
        for will be issued on the life of the annuitant? [_] Yes [_] No

____________________________________________________________________________________________________________________________________
Registered Representative Signature                                   Signed at: City and State

____________________________________________________________________________________________________________________________________
Firm/Agency Name and Address                                          Firm/Agency No.

____________________________________________________________________________________________________________________________________
Print Name & Registered Representative (JH Rep) No./Certificate Code                       SSN   Telephone No.                  %

____________________________________________________________________________________________________________________________________
Print Name & Registered Representative (JH Rep) No./Certificate Code                       SSN   Telephone No.                  %

Please check one of the following Comm Options (Contact your Home Office for more information)
[[_] Option A   [_] Option B  [_] Option C]
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State Disclosures
[For all states except CO, CT, DC, KY, NJ, OH, OK, PA, TX and VA:

Any person who, with intent to defraud or knowing that he is facilitating a
fraud against an insurer, submits an application or files a claim containing a
false or deceptive statement may be guilty of insurance fraud.

For Arizona Residents Only:

On written request, we are required to provide within a reasonable time,
reasonable factual information regarding the benefits and provisions of the
annuity certificate to your. If for any reason, you are not satisfied with the
annuity certificate you may return it within ten days after the certificate is
delivered and receive a refund of all monies paid. For variable annuity
certificates, the refund shall equal the sum of the difference between the
premiums paid, including any policy or certificate fees or other charges, and
the amounts allocated to any separate accounts under the policy or certificate,
and the value of the amounts allocated to any separate accounts under the policy
or certificate on the date the returned certificate is received by the insurer
or its agent.

For Connecticut Residents only:

Any person who, with intent to defraud or knowing that he is facilitating a
fraud against an insurer, submits an application or files a claim containing a
false or deceptive statement is guilty of insurance fraud, as determined by a
court of competent jurisdiction.

For District of Columbia Residents only:

WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER
FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE
IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS
IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE
APPLICANT.

For Kentucky Residents only:

Any person who knowingly and with the intent to defraud any insurance company or
other persons, submits an application or files a statement of claim containing
any materially false information, or conceals for the purpose of misleading,
information concerning any facts, material thereto, commits a fraudulent act,
which is a crime.

For New Jersey Residents only:

Any person who includes any false or misleading information on an application
for an insurance policy is subject to criminal and civil penalties.
For Ohio Residents only:

Any person who knowingly and with intent to defraud any insurance company or
other persons, submits an application or files a claim containing any materially
false information, or conceals for the purpose of misleading, information
concerning any facts, material thereto, commits a fraudulent act, which is a
crime.

For Oklahoma Residents only:

WARNING: Any person who knowingly and with intent to injure, defraud, or deceive
any insurer, makes a claim for the proceeds of an annuity containing any false,
incomplete or misleading information is guilty of a felony.

For Pennsylvania Residents only:

Any person who, knowingly and with intent to defraud any insurance company or
other person, files an application for insurance or statement of 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.

For Texas Residents only:

Any person who, with intent to defraud or knowing that he is facilitating a
fraud against an insurer, submits an application or files a claim containing a
false or deceptive statement may be guilty of insurance fraud.

For Virginia Residents only:

Any person who, with the intent to defraud or knowing that he is facilitating a
fraud against an insurer, submits an application or files a claim containing a
false or deceptive statement may have violated state law.]

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