LIBERTY LIFE ASSURANCE COMPANY OF BOSTON VARIABLE LIFE INSURANCE SUPPLEMENTAL APPLICATION

1. PLAN

o Single Premium Single Life Variable Life Insurance

o  Single Premium Last Survivor Variable Benefit Agreement 

o Flexible Premium Single Life Variable Life Insurance

o Other

2. INSURED A

First

MI

Last

Date of Birth

Social Security Number

/           /

-         -

3. INSURED B

First

MI

Last

Date of Birth

Social Security Number

/           /

-         -

PAYMENT ALLOCATION 

Allocations must total 100%.

The minimum percentage allocation is [5%] and must be in whole numbers.

4. ASSET ALLOCATION MODEL

If chosen do not complete allocation percentages below. 

Asset Allocation Models are rebalanced quarterly.

4A. FIXED ACCOUNT 

%

4B. SUB-ACCOUNTS 

Please make no more than [10] selections

AIM V.I. Government Securities

%

Dreyfus IP Technology Growth

%

MFS VIT High Income

%

AIM V.I. International Growth

%

Dreyfus Stock Index

%

MFS VIT Utilities

%

AIM V.I. Technology

%

Dreyfus VIF Appreciation

%

MFS VIT Investors Trust

%

AIM V.I. Capital Appreciation

%

Dreyfus Socially Responsible Growth

%

MFS VIT Research

%

Columbia Strategic Income

%

Dreyfus IP Emerging Leaders

%

MFS VIT Capital Opportunities

%

Columbia High Yield

%

Franklin Money Market

%

MFS VIT Emerging Growth

%

Columbia Large Cap Value

%

Franklin Strategic Income

%

Columbia Money Market

%

Columbia Small Cap Value

%

▇▇▇▇▇▇▇▇▇ Growth

%

Columbia Asset Allocation

%

Franklin Growth and Income

%

Columbia Large Cap Growth

%

Franklin Large Cap Growth

%

Other

%

SPECIAL REQUESTS

Yes

No

5.

Is Dollar Cost Averaging elected?

o

o

6.

Is Account Rebalancing elected? (Do not complete if an Asset Allocation Model is used.)

o

o

7.

Please indicate if you refuse Telephone Transfer privileges. o

If you answered Yes to questions 5 or 6, applicable administrative form(s) must be completed and submitted for your elections to be effective.

SUITABILITY

PLEASE READ CAREFULLY

Yes

No

8.

Did you receive the current prospectus for the life contract applied for?

o

o

9.

Do you understand that the contract values including the Death Benefit may increase or decrease, depending on the investment performance of the sub-accounts?

o

o

10.

Do you understand that the contract may lapse only if the surrender value becomes insufficient to cover the Monthly Deductions?

o

o

11.

Do you understand that the initial payment may be held in the Fixed Account until after your Right to Return period expires?

o

o

12.

Do you believe that this contract is consistent with your insurance needs and financial objectives?

o

o

Signature of Insured A

Signature of Insured B

Signature of Joint Owner

Signature of Owner if Other than Insured(s)

Dated at 

on

City and State

Date

Signature of Registered Representative