Electronic Funds Transfer Information - Disbursement

---

Electronic Funds Transfer Information - Disbursement •

The information below needs to be completed if you wish to have your disbursement electronically wired to your bank.

IMPORTANT: In order to expedite your request, please also provide a void check in addition to completing this form. This form and the void check need to be provided in addition to the other forms in the package you have received. The funds will only be released if all requirements have been met.

Insured Name Policyowner’s Name Policy No. Name of Bank Name of Account Holder Owner’s Account No. Address of Bank City, State, Zip Code Bank Telephone No. (include area code) Bank ABA/Routing (9 digits) (ABA number must be specific for a Wire transfer)

Attention/Re: For Credit to the Account of

Date Signature of Owner/Trustee Signature of Collateral Assignee

Name - please print

Title

PS5158US (08/2013)

Insurance products are issued by: John Hancock Life Insurance Company (U.S.A.) (not licensed in New York), Boston, MA 02116; John Hancock Life Insurance Company of New York, Valhalla, NY 10595 and John Hancock Life & Health Insurance Company, herein collectively referred to as John Hancock.