<PAGE> 1
EXHIBIT (10)
SINGLE LIFE
APPLICATION
PART I
NEW YORK LIFE INSURANCE COMPANY
NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION
NYLIFE INSURANCE COMPANY OF ARIZONA
SINGLE LIFE
[PHOTO]
998-501
<PAGE> 2
<TABLE>
<CAPTION>
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GENERAL REQUIREMENTS FOR VARIOUS TYPES OF REQUESTED ACTIONS
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ACTION REQUESTED ENTRY IN HEADING QUESTIONS REQUIRING AN ANSWER
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<S> <C> <C>
Amending Previous Insert application date in Ques. 1, 2-7 for application items being amended; 8 & 9 if cash
Application (Policy not "Amend Application Dated" being paid; 18 to delete riders; 21 (unless a required Part II not
delivered) yet completed or unless temporary coverage is still in effect and
change does not increase risk).
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Add-on rider, increase in face Insert Policy Number in Ques. 1, 2 for add-on, 6, 8, 9, 11-13; also 14-17 for new coverage
amount of policy (for UL/Target "Change Request" and check within Simplified Underwriting limits." For Increase.
Life and VUL) only on policies Box ---------------------------
issued after 1/1/85 indicate "Increase Face Amount to $ "
in Ques. 18. ---------------------------
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PPO/GIO or TEmPPO Check "GIO/PPO/GIR/SPO" Ques. 1, 2, 4-7, 9, and 22. For UL/Target Life, indicate "Increase
Option, GIR Option to Box, and insert basic Policy ------------------
increase face amount of Number Face Amount to $ " in Ques. 18 instead of
UL/Target Life or VUL Policy ------------------
completing Ques. 2 Completion of Ques. 12 is required only if
necessary, e.g., where the original policy was issued prior to age
18.
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Term Conversion Insert Policy Number and Ques. 1, 2, 4, 5 (attained age only), 6, 7, 9, and 23. Completion
check appropriate of Ques. 12 is required only if necessary, e.g., where the original
"Conversion" Boxes policy was issued prior to age 18.
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Reinstatement Insert Policy Number and Within 6 mos. if underwriting required; Ques. 1, 8, 9, 12, 13, 14-
check "Reinstatement" Box 17."
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Reduction in Rating Insert Policy Number and Ques. 1, 8, 12, and 13. In Ques. 18, enter "Request for Reduction
check "Change Request" Box ----------------------
of Rating for ."
----------------------
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Reconsideration for Non- Insert Policy Number and Ques. 1, 8, 12, and 13. In Ques. 18, enter "Request for
Smoker or Preferred Risk check "Change Request" Box ---------------------
Reconsideration to ."
---------------------
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</TABLE>
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ADDITIONAL INFORMATION
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If cash is being paid with amendment, the total cash paid must be at least one
month's premium for the policy on the changed basis. Only the indicated changes,
including deletions, will be made.
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If Ques. 8(a) or 8(b) are answered "Yes", cash may not be paid and Simplified
Underwriting is not available - Part II required. See "Quick check card 13047"
and Agents' Manual. Sect. UND VI for coverage beyond Simplified Und. limits.
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For amounts in excess of option amounts, see Agents' Manual. Section UND
VI.
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For additional coverage: Ques. 8, 12, 13. Also 14-17 if a Simplified
Underwriting case.*
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After 6 mos.: See Agents' Manual. Section UND VI.
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APS if required. See Agts.' Manual for appropriate Part II's. Occupation: in
Ques. 18, give dates and describe occupations in last 5 years or since issue
date, if less. Avocation or Aviation: From 7663. Driving Record: Give Lic. No.
in Q.1.
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Simplified Und. or Appropriate Part II. See Agents' Manual, Section UND VI.
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*If a Part II is required, omit Questions 14-17.
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GENERAL BENEFICIARY INSTRUCTIONS FOR COMPLETING APPLICATION
1. Complete Section A (Standard Beneficiary Designations) or Section B (Named
Beneficiary). Do not complete both sections. Only one box can be checked in
Section A. If more than one box applies, use Section B.
2. Always include first and last name and middle initial (if applicable) i.e.
Jane M. Smith
SECTION B-NAMED BENEFICIARY INSTRUCTIONS
Specify order, shares (in fractions), full name of beneficiary(s) and
relationships(s) to Insured.
<TABLE>
<CAPTION>
EXAMPLE CLASS BENEFICIARY NAME SHARES RELATIONSHIP
<S> <C> <C> <C> <C>
Fractional Shares: 1st Mary Doe 3/4 spouse
2nd John Doe son
1st Jane Doe 1/4 mother
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Split Dollar: 1st ABS Corporation A
1st Mary Doe B spouse
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Other Covered Insureds:
Primary Insured: 1st Mary Doe spouse
Other Covered Insured: 1st John Doe spouse
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Creditors: 1st ABC Inc as its interests may appear
1st Balance to Mary Doe. spouse
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Last Will And Testament: 1st United Bank of Missouri as trustee under will dated September 14,
1984
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*For Split Dollar, Must indicate Part A and Part B beneficiary. In question 3, check off whether Basic or Estate, and Contributory
or Non-Contributory.
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</TABLE>
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NAMES AND ADDRESSES OF FOUR FRIENDS AND RELATIVES
1. 3.
------------------------------------ -------------------------------------
------------------------------------ -------------------------------------
2. 4.
------------------------------------ -------------------------------------
------------------------------------ -------------------------------------
<PAGE> 3
RF575101
LIFE INSURANCE APPLICATION (PART I) TO:
[] NEW YORK LIFE INSURANCE COMPANY (NYLIC) 51 Madison Ave., New York, NY 10010
[] NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION (NYLIAC) (A Delaware Corp.)
51 Madison Ave., NY, NY 10010
[] NYLIFE INSURANCE COMPANY OF ARIZONA (NOT LICENSED IN EVERY STATE)
2398 E. Camelback Rd. Suite 500, Phoenix, AZ 85016
[NEW YORK LIFE LOGO]
<TABLE>
<S> <C> <C> <C> <C>
[] New [] Amend Application [] Reinstatement } Pol. No. { [] Conversion [] Alt age [] Orig age
Application Dated / / [] Change Request } ------------- { [] GIO/PPO/GIR/SPO
</TABLE>
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1. PERSON PROPOSED FOR COVERAGE
[] Primary Insured is also an OCI under OCI or 5YT Rider(s)
| | | | |
Sex [] M [] F Title [] Mr [] Mrs [] Ms [] |_|_|_|_|
First/Mid | | | | | | | | | | | | | | | | | | | | | | | |
Name |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
LAST NAME | | | | | | | | | | | | | | | | | | | | | | | |
& Suffix |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
[] Maiden | | | | | | | | | | | | | | | | | | | | |
[] Known as |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Born | | | | | | | | | | |
M/D/Y |_|_|/|_|_|/|_|_|_|_| State, Ctry.
Soc | | | |_| | |_| | | | | Tax | | |_| | | | | | | |
Sec |_|_|_| |_|_| |_|_|_|_| ID# |_|_| |_|_|_|_|_|_|_|
Driver's State of | | |
License No. Issue |_|_|
Mailing
Address
City
| | | | | | | | | | | | | | Time | | | | | |
State |_|_| Zip |_|_|_|_|_|+|_|_|_|_| Yrs/Mos |_|_|/|_|_|
Prev St
(if within
2 yrs)
City
| | | | | | | | | | | | | | Time | | | | | |
State |_|_| Zip |_|_|_|_|_|+|_|_|_|_| Yrs/Mos |_|_|/|_|_|
Present
Occupation
and
Duties
Employer
Mailing
Address
City
| | | | | | | | | | | | | | Time | | | | | |
State |_|_| Zip |_|_|_|_|_|+|_|_|_|_| Yrs/Mos |_|_|/|_|_|
Prev Occupation(s)
and
Duties
(within 2 yrs)
Previous
Employer
Mailing
Address
City
| | | | | | | | | | | | | | Time | | | | | |
State |_|_| Zip |_|_|_|_|_|+|_|_|_|_| Yrs/Mos |_|_|/|_|_|
Mail Telephone | | | |_| | | |_| | | | |
Address [] Res [] Bus (Home) |_|_|_| |_|_|_| |_|_|_|_|
Best Place Telephone | | | |_| | | |_| | | | |
to Call [] Res [] Bus (Business) |_|_|_| |_|_|_| |_|_|_|_|
Best time to call between | | | | | | AM | | | | | | AM
(circle AM or PM) From |_|_|:|_|_| PM to |_|_|:|_|_| PM
<TABLE>
<CAPTION>
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2. NYLIC RIDERS DIVIDEND OPTION
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<S> <C> <C> <C> <C> <C> <C> <C>
[ ] WL [ ] MPWL [ ] WP [ ] OPP [ ] COM [ ] PPO [ ]5YTR PI [ ] MPG [ ] [ ] 1YT (Select
[ ] ADB Scheduled Bill $ $ another option for
$ [ ] IPTR [ ] DOT balance of dividends)
Face Amount $ $ Unscheduled $ [ ] [ ] Pd Up Ad
Premium $ [ ] LBR (Lump Sum) [ ] Accum
APL [ ] Yes $ [ ] UR (See Q.18(a)) [ ] Prem
$ [ ] Cash
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[ ] Spectra 1 Check any additional riders not automatically included in selected Spectra Life plan. [ ] 1YT (Select
(includes 5YTR) [ ] WP [ ] OPP [ ] COM [ ]PPO [ ] 5YTR PI [ ] MPG [ ] another option for
[ ] Spectra 2 [ ] ADB Scheduled Bill $ $ balance of Dividends)
(includes 5YTR) $ [ ] IPTR [ ] DOT [ ] Pd Up Ad
[ ] Spectra 3 $ Unscheduled $ $ [ ] Accum
(includes DOT & (Lump Sum) [ ] UR (SEE Q.18(a)) [ ] Prem
OPP riders) [ ] LBR $ [ ] Cash
Face Amount $
APL [ ] Yes
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[ ] 5YT [ ] WP [ ] 5YTR PI [ ] MPG [ ] ADB (Select one)
[ ] LBR $ [ ] [ ] Accum
Face Amount $ $ [ ] Prem
[ ] MPG [ ] Cash
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[ ] IPT [ ] WP [ ] ADB [ ] PPO (Select one)
[ ] LBR $ $ [ ] Accum
Face Amount $ [ ] Prem
[ ] Cash
Premium $
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[ ] [ ]
$
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</TABLE>
998-501 1
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RF575101
<TABLE>
<CAPTION>
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NYLAZ RIDERS
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<S> <C> <C> <C>
[ ] Term to
Age 90 [ ] WP [ ] ADB [ ]
Face Amount $ [ ] LBR $
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[ ] [ ]
$
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</TABLE>
<TABLE>
<CAPTION>
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NYLIAC RIDERS
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<S> <C> <C> <C> <C> <C>
[ ] NYLIAC Accumulator [ ] MDW [ ] ADB [ ] GIR [ ] STR [ ]
[ ] ULGUIDE [ ] ULCVAT
[ ] NYLIAC Protector $ $ $
[ ] ULGUIDE [ ] ULCVAT
Face Amount $
[ ] 1
OPTION {
[ ] 2
Planned $
Initial $
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[ ] VUL Face Amount $ [ ] MDW [ ] ADB [ ] OCI PI [ ]
[ ] LBR $ $
[ ] 1 [ ] GIR [ ] GMDB
OPTION { $ to Age [ ] 70
[ ] 2 to Age [ ] 80
Sched. $ to Age [ ] 95
Initial $
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[ ] Spectra VUL 70 [ ] Spectra VUL 80 [ ] MDW [ ] ADB [ ] OCI PI [ ]
[ ] GIR $ $
$ [ ] LBR
[ ] Spectra VUL 95
[ ] 1
OPTION {
[ ] 2
Face Amount $
Sched. $
Initial $
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[ ] Asset Preserver (UL/LTC) Submit completed Asset Preserver Application Supplement
Face Amount $
Premium $
Option: [ ] LTC 24
[ ] LTC 36+
[ ] LTC 48+
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[ ] SPL
Face Amount $ [ ] LBR [ ]
Premium $
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[ ] [ ]
$
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INSURANCE IN FORCE OR PENDING
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Yes No
Do you have other Life Insurance (all Companies) in force [ ] [ ] If "Yes", Total Amount in all Companies
Yes No $
Do you have other Life Ins. (all Cos.) pending or issued in last year? [ ] [ ] If "Yes", Company
Amount $ Plan No.
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3. ENDORSEMENTS AND OTHER REQUESTS
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U.S. Tax Qualified: [ ] TSA [ ] Pens. Trust [ ] Keogh [ ] 403(B) [ ]
[ ] 401(A) [ ] 401(K) [ ] 457
Split Dollar: [ ] Basic [ ] Estate [ ] Contributory [ ] Non-Contributory
Pension Option [ ] Yes "Non-Trsf." Option [ ] Yes Reduced Pd. Up at lapse [ ] Yes
Preliminary Term to M/D/Y |_|_| / |_|_| / |_|_|_|_| (Available on WL, MPWL Only) Note: Policy Date question
is not applicable if prelim. term
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</TABLE>
998-501
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RF575101
<TABLE>
==================================================================================================================================
<S> <C> <C>
4. MODE [ ] Ann [ ] Semi [ ] Qrtly [ ] COM [ ] Nyla [ ] Gvt [ ] Arr. for U.S. Tax Qual. Plan [ ] (All modes not available
on all plan)
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</TABLE>
<TABLE>
<S><C> <C> <C>
5. POLICY DATE If no "other date" is shown, policy date is: (c) the option date, if insurability option being exercised; or
(a) later date of Part I and any required Part II, if cash
paid with Part I; or (d) OTHER
(b) the policy's date of issue, if cash not paid; or DATE M/D/Y |_|_| / |_|_| / |_|_|_|_|
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</TABLE>
<TABLE>
<CAPTION>
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6. REPLACEMENT
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<S><C> <C>
(a) Does the life insurance for which you are applying replace, in whole or in part, any existing life insurance or annuity Yes No
contract(s)? [ ] [ ]
(b) Do you intend, now or in the future, to take a loan against the cash value of any policy presently in force, because
of the new policy for which you are applying? [ ] [ ]
(c) Is the policy for which you are applying the result of a 1035 Exchange? [ ] [ ]
If "Yes" to any of the above, Name of Insured Company
Pol. No. Type of Plan Amount $
If more than one policy is being replaced, use "Details, Q.18".
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7. BENEFICIARY (SUBJECT TO CHANGE) COMPLETE SECTION A OR B. MUST COMPLETE SECTION B FOR NON-STANDARD BENEFICIARY.
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</TABLE>
<TABLE>
<S><C> <C> <C>
A. Standard Beneficiary Designations (select one)
[ ] Spouse [ ] Estate
[ ] 1st, Spouse [ ] 1st, Spouse
2nd, Children of marriage 2nd, Children of marriage and legally adopted
[ ] 1st, Spouse [ ] 1st, Spouse
2nd, Children of marriage and named children 2nd, Named children
[ ] Trust
Name of Trustee Name of Trust Date of Trust
[ ] Uniform Transfers to Minors
as custodian for under the Uniform Transfers/Gifts Minors Act (UTMA)
(Minor) (State)
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</TABLE>
<TABLE>
<S> <C> <C>
B.[ ] Named Beneficiaries (indicate Order as 1st, 2nd, etc.)
Order Full Name Relationship
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</TABLE>
<TABLE>
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8. CURRENT HEALTH
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<S> <C> <C>
(a) In the last 2 years: have you been unable to work or unable Yes No
to attend school or been disabled for one month or more? [ ] [ ]
(b) In the last 2 years, have you been in a hospital or other medical
facility for more than 5 consecutive days? [ ] [ ]
Note: If "Yes" to either part of Question 8, cash CANNOT be paid and an
Application Part II must be completed in all cases.
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</TABLE>
<TABLE>
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<S> <C> <C>
9(a). Answer if cash is intended to be paid with this application. Is it agreed that cash will be received subject to the Yes No
terms of the attached receipt, that any coverage will be provided only as stated in the attached receipt and only if [ ] [ ]
all conditions to coverage are met, and that any such coverage will be temporary and limited in amount?
If "No" to 9(a), or if Questions 8(a) or 8(b) are answered "Yes", cash cannot be paid.
(b) TOTAL CASH PAID? $ If amendment, cash previously paid: $
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</TABLE>
<TABLE>
<S> <C> <C> <C>
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10. Is a spouse or dependent child applying for SCI/CI Ins. coverage? (If yes, this form must
not be used; use Multilife application form) Yes [ ] No [ ]
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11. INSURANCE ON CHILD Answer if Proposed Insured is under 14 yrs. 6 mos.
(explain any "No" in Details, Q. 18.1.)
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</TABLE>
<TABLE>
<S> <C> <C>
Yes No
(a) Is Applicant a parent or legal guardian (attach proof of guardianship) of Proposed Insured? ...................... [ ] [ ]
(b) Is Applicant employed and providing Proposed Insured's main support? ............................................. [ ] [ ]
(c) Is all life insurance in force on Applicant at least equal to that on Proposed Insured? .......................... [ ] [ ]
If Child resides in NY and age is over 4 yrs 6 mos is amount in force on applicant at least equal to 2 times
amount on Child? ................................................................................................. [ ] [ ]
If Child resides in NY and age is under 4 yrs 6 mos is amount in force on applicant at least equal to 4 times
amount on Child? ................................................................................................. [ ] [ ]
(d) Are all other children in family insured or to be insured for an amount at least equal to that on Proposed
Insured? ......................................................................................................... [ ] [ ]
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</TABLE>
998-501 3
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RF575101
<TABLE>
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<S><C> <C>
12. TOBACCO/NICOTINE
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If age 18 or over on Policy Date, have you used tobacco or nicotine in any form, in the last 5 years?.....................YES NO
If "Yes", indicate type used date of last use (Mo/Yr) / [ ] [ ]
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</TABLE>
<TABLE>
<S> <C> <C> <C>
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13. UNDERWRITING DATA
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(a) In last 2 years, have you engaged in or do you
now intend to engage in? If "Yes", submit Form
7663
aircraft flying, other than as a passenger [ ]YES [ ]NO
motorcycle driving [ ]YES [ ]NO
snowmobile driving [ ]YES [ ]NO
motorized racing [ ]YES [ ]NO
scuba diving [ ]YES [ ]NO
ballooning [ ]YES [ ]NO
parachuting [ ]YES [ ]NO
hang gliding [ ]YES [ ]NO
ultralight flying [ ]YES [ ]NO
mountaineering [ ]YES [ ]NO
rodeo riding [ ]YES [ ]NO
Each part of this ques. is answered: [ ]NO
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(b) Do you have a current driver's license? YES NO
[ ] [ ]
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(c) In the last 5 years, have you had your driver's
license suspended or revoked? If yes, give YES NO
details, dates, driver's license # and [ ] [ ]
state of license in Details, Q. 18.
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(d) In last 5 years, have you been arrested,
convicted or imprisoned for any reason? YES NO
If yes, give details in Q. 18. [ ] [ ]
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(e) Are you a citizen of the United States? YES NO
If no, give country of citizenship in Q. 18. [ ] [ ]
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(f) In last 2 years, have you traveled or
resided outside the U.S. or Canada or
do you intend to do so within the next 12 months?
If yes, give Where, When, How long in Details, YES NO
Q. 18. [ ] [ ]
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(g) In last 2 years, have you been declined for
issue, reinstatement or renewal of any type
of Life or Health Insurance? If yes, give YES NO
Company name and reason in Details, Q. 18. [ ] [ ]
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Details are required for all "Yes" answers to Question 14-17. Do not answer 14-17 if a Part is required.
</TABLE>
<TABLE>
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14. MEDICAL UNDERWRITING
----------------------------------------------------------------------------------------------------------------------------------
<S> <C>
(a) In last 10 years have you
had or been treated for:
heart disorder [ ] Yes [ ] No
angina [ ] Yes [ ] No
stroke [ ] Yes [ ] No
irregular pulse [ ] Yes [ ] No
hypertension [ ] Yes [ ] No
diabetes [ ] Yes [ ] No
cancer [ ] Yes [ ] No
tumor [ ] Yes [ ] No
Each part of this Q. is answered: [ ] No
----------------------------------------------------------------------------------------------------------------------------------
(b) In last 10 years have you
been counseled, treated, or
hospitalized for:
psychiatric condition [ ] Yes [ ] No
emotional condition [ ] Yes [ ] No
mental health condition [ ] Yes [ ] No
Each part of this Q. is answered: [ ] No
----------------------------------------------------------------------------------------------------------------------------------
(c) In last 10 years have you used
cocaine [ ] Yes [ ] No
or other controlled substance [ ] Yes [ ] No
or have you been counseled,
treated or hospitalized for
drug use [ ] Yes [ ] No
Each part of this Q. is answered: [ ] No
----------------------------------------------------------------------------------------------------------------------------------
(d) In last 10 years have you been
absent from work because of
alcohol use [ ] Yes [ ] No
or have you been counseled,
treated or hospitalized for
alcohol use [ ] Yes [ ] No
Each part of this Q. is answered: [ ] No
----------------------------------------------------------------------------------------------------------------------------------
15. In last 2 years have you had or
been treated for:
(a) unexplained weight loss [ ] Yes [ ] No
swollen glands [ ] Yes [ ] No
recurring diarrhea [ ] Yes [ ] No
recurring fever [ ] Yes [ ] No
recurring infection [ ] Yes [ ] No
persistent cough [ ] Yes [ ] No
pneumonia [ ] Yes [ ] No
thrush [ ] Yes [ ] No
Each part of this Q. is answered: [ ] No
----------------------------------------------------------------------------------------------------------------------------------
(b) edema [ ] Yes [ ] No
transient visual loss [ ] Yes [ ] No
muscle weakness [ ] Yes [ ] No
back or spine disorder [ ] Yes [ ] No
shortness of breath [ ] Yes [ ] No
internal bleeding [ ] Yes [ ] No
Each part of this Q. is answered: [ ] No
----------------------------------------------------------------------------------------------------------------------------------
16. In last 5 years have you had
or been treated for:
(a) chronic respiratory disorder [ ] Yes [ ] No
kidney disorder [ ] Yes [ ] No
intestinal disorder [ ] Yes [ ] No
blood disorder [ ] Yes [ ] No
circulatory disorder [ ] Yes [ ] No
seizures [ ] Yes [ ] No
other nervous system disorder [ ] Yes [ ] No
Each part of this Q. is answered: [ ] No
----------------------------------------------------------------------------------------------------------------------------------
(b) liver disorder [ ] Yes [ ] No
pancreas disorder [ ] Yes [ ] No
immune system disorder
(including AIDS or AIDS-
Related Complex) [ ] Yes [ ] No
Each part of this Q. is answered: [ ] No
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17. Your height (ft., in.) Your weight (lbs.)
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</TABLE>
998-501 4
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RF575101
================================================================================
18. Details: Give nature and severity, dates and duration, treatment, including
prescription medication, and results for each "Yes" answer to questions 14,
15 and 16. Also use this space for any other additional details and special
requests. (Indicate Ques. No. if applicable).
<TABLE>
<CAPTION>
<S> <C> <C>
Q.# |Details |Name, Addr of Dr./Hosp.
| |
------|----------------------------------------------------------------------|----------------------------------------------------
| |
------|----------------------------------------------------------------------|----------------------------------------------------
| |
------|----------------------------------------------------------------------|----------------------------------------------------
| |
------|----------------------------------------------------------------------|----------------------------------------------------
| |
------|----------------------------------------------------------------------|----------------------------------------------------
| |
------|----------------------------------------------------------------------|----------------------------------------------------
| |
------|----------------------------------------------------------------------|----------------------------------------------------
| |
------|----------------------------------------------------------------------|-----------------------------------------------------
| |
------|----------------------------------------------------------------------|----------------------------------------------------
| |
------|----------------------------------------------------------------------|----------------------------------------------------
| |
------|----------------------------------------------------------------------|----------------------------------------------------
| |
------|----------------------------------------------------------------------|----------------------------------------------------
| |
------|----------------------------------------------------------------------|----------------------------------------------------
| |
------|----------------------------------------------------------------------|----------------------------------------------------
| |
------|----------------------------------------------------------------------|----------------------------------------------------
| |
------|----------------------------------------------------------------------|----------------------------------------------------
| |
======|===========================================================================================================================
18(a) | Answer for UR rider only:
2 | Have you been continuously employed for the past two years? [ ] Yes [ ] No
| Have you received unemployment benefits in the last two years? [ ] Yes [ ] No
==================================================================================================================================
19. APPLICANT (IF NOT PROPOSED INSURED) |
-------------------------------------------------------
First/Mid|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| Street
Name
LAST NAME|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| City
& Suffix
Born |_|_|/|_|_|/|_|_|_|_| State |_|_|Zip |_|_|_|_|_|+|_|_|_|_|
M/D/Y
Soc |_|_|_|-|_|_|-|_|_|_|_| Tax|_|_|-|_|_|_|_|_|_|_| Employer
Sec ID#
Business
Street
Relationship to Proposed Insured
[ ] Spouse [ ] Parent [ ] Employer [ ] UTMA [ ]
City
Address [ ] Same as PI Res [ ] Same as PI Bus Mail
[ ] other as follows State |_|_|Zip |_|_|_|_|_|+|_|_|_|_|Address [ ] Res [ ] Bus
==================================================================================================================================
20. OWNER (IF NOT PROPOSED INSURED) |
-------------------------------------------------------
First/Mid|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| Street
Name
LAST NAME|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| City
& Suffix
Born |_|_|/|_|_|/|_|_|_|_| State |_|_|Zip |_|_|_|_|_|+|_|_|_|_|
M/D/Y
If Corp., Date |_|_|_|_|_|_|
Soc |_|_|_|-|_|_|-|_|_|_|_| Tax|_|_|-|_|_|_|_|_|_|_| Where Inc. Inc. MO DAY YR
Sec ID#
Successor Owner Relationship
Relationship to Proposed Insured [ ] PI [ ] as below to Prop Insd
[ ] Spouse [ ] Parent [ ] Employer [ ] UTMA [ ]
Are you a citizen of the United States? [ ] Yes [ ] No Name |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
If no, give country of citizenship
Mailing Address [ ] Same as PI's [ ] Same as Applic's [ ] other as follows
[ ] Check if multiple owners. Give additional name, birthdate, SS#, relationship in Details, Question 18. Unless otherwise
specified in Question 18, if more than one owner is shown, ownership will be joint with right of survivorship.
==================================================================================================================================
21. AMENDING APPLICATION PREVIOUSLY SUBMITTED.
----------------------------------------------------------------------------------------------------------------------------------
Since the date the application for the policy (including any Part II) was completed, have you Yes No
(a) been admitted to a hospital, sanitarium, or other medical facility? If "Yes" to (a), submit a new [ ] [ ]
application Part II.
(b) had any illness, or consulted any physician or practitioner for any reason? If "Yes" to (b), give [ ] [ ]
full details in Q. 18.
==================================================================================================================================
</TABLE>
998-501 5
<PAGE> 8
<TABLE>
<CAPTION>
<S> <C> <C>
==================================================================================================================================
22. EXERCISING A GUARANTEED INSURABILITY OPTION.
----------------------------------------------------------------------------------------------------------------------------------
(a) Option Date (b) [ ] Scheduled Option Date [ ] Alternate Option Date
(c) If Alternate Option Date [ ] date of marriage [ ] birth [ ] adoption Mo. Day Year Submit proof of event
==================================================================================================================================
23. EXERCISING CONVERSION PRIVILEGE FROM TERM COVERAGE TO PERMANENT INSURANCE
----------------------------------------------------------------------------------------------------------------------------------
The Insurer is requested to issue the policy applied for on the Age Basis selected and continue the following Rider(s) to the
Policy(ies) listed on Page 1 of this application, as indicated below, when the policy applied for takes effect.
Age Basis Convert All: Convert Partial:
[ ] Attained Age [ ] term policy [ ] Term policy (with pro rata reduction of any ADB)
[ ] Original Age [ ] term rider $ amount remaining as term policy
[ ] 1 YT Div Opt [ ] Term rider
[ ] OCI/5YTR $ amount remaining as term rider
Does the coverage to be converted include Waiver of Premium Benefit? [ ] Yes [ ] No
If "Yes", does the Insured have any disability which prevents him or her
from being actively at work? [ ] Yes [ ] No
If "Yes", give dates and details in Q. 18
Is Additional coverage being applied for? [ ] Yes [ ] No If "Yes", refer to General Requirements for Various Types of Requested
Actions
</TABLE>
===============================================================================
THOSE PERSONS WHO SIGN BELOW AGREE THAT:
1. All of the statements which are part of the application are correctly
recorded, and are complete and true to the best of the knowledge
and belief of those persons who made them. Answers that are not true
and complete may, subject to the policy's Incontestability Provision,
invalidate coverage.
2. No agent or medical examiner has any right to accept risks, make or
change contracts, or give up any of NYLIC's, NYLIAC's, or NYLAZ's rights
or requirements.
3. "Cash Paid" with the application, with respect to a new policy or
additional benefit, provides a limited amount of temporary coverage for
up to 90 days, if the terms and conditions of the receipt are met.
Temporary coverage is not provided if a policy or benefit is applied
for under the terms of a conversion privilege or a guaranteed
insurability option, or if reinstatement is applied for.
4. To put a policy or benefit issued in response to this application in
force, the policy or written evidence of the benefit must be delivered
to the Applicant and the full first premium paid while the person to
be covered is living. If temporary coverage, with respect to a policy
or benefit, is not in effect at time of delivery, there must not have
been any material change in the insurability of that person, as
described by the statements in the application; this means that these
statements must still be complete and true as if made at the time of
delivery.
However, if the policy or benefit is being applied for under the terms
of a conversion privilege or guaranteed insurability option, and
NYLIC's, NYLIAC's, or NYLAZ's approval is not required to put it in
force, the policy or benefit will take effect as soon as the
requirements of that privilege or option have been met.
----------------------------------------------------------------------------
5. Under penalties of perjury, I (as the owner named in Question 1 or 20)
certify that (1) the Social Security or Employer ID Number shown in
this application is my correct taxpayer identification number, or I am
awaiting a number to be issued to me (write "awaiting TIN" in Question
20) AND (2) I am not subject to backup withholding because: (a) I am
exempt from backup withholding; or (b) I have not been notified by the
IRS that I am subject to backup withholding as a result of a failure to
report all interest or dividends; or (c) the IRS has notified me that
I am no longer subject to backup withholding. (Cross out Item 2 if the
IRS has notified you that you are subject to backup withholding.)
THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY
PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO
AVOID BACKUP WITHHOLDING
--------------------------------------------------------------------------------
<TABLE>
<S> <C> <C>
Dated at on Mo/Day/Yr / /
I certify I have truly and accurately Signature of Applicant
recorded all answers given to me.
Witness Other Required Signature Signature of Owner if other than
Applicant
Agent
Signature of Proposed Insured, if
other than Applicant
Countersigned by Lic. resident agt. (if reqd.) Signature of Parent if Proposed Insured is
under 14 yrs. 6 mos. and Parent has not
signed as Applicant
Countersign Code# Surname Title if signed on behalf of
corporation, trust, etc.
Print Agent's Name
The signatures above apply to the application and the certification of Taxpayer Identification Number
==================================================================================================================================
</TABLE>
998-501
<PAGE> 9
ACKNOWLEDGEMENT
I have been given a copy of "Information Practices Related to
Underwriting Your Application" which tells how New York Life Insurance Company,
New York Life Insurance and Annuity Corporation and NYLIFE Insurance Company of
Arizona obtain and use data about me. It includes the notice required by the
state and federal Fair Credit Reporting Acts and a description of MIB, Inc.
(Medical Information Bureau).
AUTHORIZATION
(In this Authorization, "the Insurer" means New York Life Insurance
Company, New York Life Insurance and Annuity Corporation, or NYLIFE Insurance
Company of Arizona, whichever applies.) In order to see if (and on what basis) I
qualify for insurance or for the benefits which that insurance may provide, I
authorize the following:
MEDICAL INFORMATION Physicians or practitioners; hospitals; medical or medically
related facilities; laboratories; insurance companies; or MIB may give to the
Insurer (or any consumer reporting agency acting in its behalf) and to any of
its reinsurers data and copies of records that they may have about my physical
and mental health. The data and records may include important history, findings,
diagnoses and treatment.
OTHER UNDERWRITING INFORMATION MIB and other insurance companies may give to the
Insurer and to any of its reinsurers data about: my driving record; any criminal
activity or association; hazardous sport or aviation activity; use of alcohol or
drugs; any claim of eligibility for disability income benefits; and other
applications for insurance.
EXAMINATIONS AND TESTS The Insurer may obtain physical examinations or medical
tests deemed necessary to underwrite my application. These tests (where
permitted by law) may include, but are not limited to, electrocardiograms, chest
x-rays and tests of blood and urine to determine, among other things, exposure
to causative agents of disease (for example, exposure to the AIDS virus) and the
presence of drugs. However, a separate notification/authorization form will be
provided with respect to testing for the AIDS virus.
INVESTIGATIVE CONSUMER REPORT The Insurer may obtain an investigative consumer
report and may give the consumer reporting agency information concerning the
amount and type of my coverage and my use, if any, of tobacco. The report may
add to or confirm the types of data mentioned above. It may also contain data
about: my identity; age; residence; marital status; past and present jobs
(including work duties); economic conditions; driving record; personal and
business reputation in the community; and mode of living; but will not include
any information relating directly or indirectly to sexual orientation.
IDENTIFICATION To obtain the data described above, the Insurer may give my name,
address, and date and place of birth to the above persons or organization.
RELEASE OF INFORMATION TO OTHERS When necessary, the Insurer may give data about
me that affects my insurability to: its subsidiaries; its affiliates; its parent
company; its agents and their staffs; its reinsurers; and the Insurer and its
reinsurers may give such data to MIB. However, this will not be done in
connection with information relating to the AIDS virus.
I also authorize the release of these same types of data about any of my
children who are to be insured.
This authorization shall be valid for 30 months from the date shown
below. A photocopy of it shall be as valid as the original.
In giving this authorization, I release the above parties from all
liability in the securing and use of the above underwriting data.
<TABLE>
<S> <C> <C> <C>
Date , Witness
--------------- ----- -------------------- ---------------------------------------- -----------------------------
Agent Signature of Parent or Guardian if the Signature of Proposed Insured
Prop. Insd. is under 14 yrs. 6 mos.
</TABLE>
17852 2-99(S)
--------------------------------------------------------------------------------
RF575101
[] NEW YORK LIFE INSURANCE COMPANY
[] NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION
[] NYLIFE INSURANCE COMPANY OF ARIZONA
(In this receipt, "we" and "our" mean the Insurer
checked above.)
Received from , on
------------------------------------------ -------------------
the sum of Dollars ($ ).
----------------------------------------------- ----------
This amount is specified in Question 9 of Part I of an application bearing the
same date and number as this receipt. This payment is received subject to the
provisions of this receipt and its Conditional Temporary Coverage Agreement
below.
If the application modifies a previous application and a payment was made
in connection with the previous application, this receipt replaces and cancels
any receipt which was previously given for that payment. We shall have no
liability on account of the previous receipt or any temporary coverage provided
under it. Our liability on account of any payment made with this application
shall be as provided under this receipt and its Conditional Temporary Coverage
Agreement below.
Any check tendered must be made payable to New York Life Insurance
Company, New York Life Insurance and Annuity Corporation, or NYLIFE Insurance
Company of Arizona as shown above. DO NOT make any check payable to the Agent.
DO NOT leave the Payee blank. Any check will be received subject to collection.
This receipt is not transferable.
-----------------------------------
Agent's Signature
CONDITIONAL TEMPORARY COVERAGE AGREEMENT (LIMITED IN AMOUNT)
1. COVERAGE NOT PROVIDED. No coverage is provided under this receipt:
(a) unless all of the Conditions to Coverage in paragraph 2 are fully
met;
(b) for suicide or intentionally self-inflicted injury;
(c) if reinstatement of a policy is being applied for;
(d) for a policy or benefit that is applied for under the terms of a
conversion privilege or guaranteed insurability option. If that
policy or benefit does not require our approval to put it in
force, it will take effect as soon as the requirements of that
privilege or option have been met.
2. CONDITIONS TO COVERAGE. The Conditions to Coverage are as follows:
(a) Any required application Part II and any medical or paramedical
examination, which is part of the initial requirements for this
application, must have been completed;
(b) All statements which are in the application for the policy,
including both Part I and any required Part II, must be complete
and true, to the best of the knowledge and belief of those persons
who made them;
(c) Questions 8(a) and 8(b) must have been answered "No"; and
(d) The sum paid in exchange for this receipt must be enough to
provide a least one month's coverage for the face amount of
insurance and under any riders being applied for.
3. AMOUNT OF COVERAGE -- MAXIMUM LIMITATIONS. The temporary coverage will
provide the same benefits as the policy applied for. It will also be
subject to the same provisions, conditions, exceptions, limitations and
reductions, that would apply under the policy had it become effective.
However, THE AGGREGATE LIABILITY on account of all the temporary coverage
for all insurers listed above, under this and any other receipt on the
person proposed for coverage in the application, for all benefits
(including any Accidental Death Benefits and any other benefits) SHALL IN
NO EVENT EXCEED $1,000,000 in total; and such liability shall be further
limited for any disabil-
998-501
<PAGE> 10
ity waiver of premium benefit so that it does not exceed $300 per month.
4. DATE COVERAGE BEGINS. The temporary coverage will begin on the LATEST of the
following dates:
(a) The date of completion of any required application Part II and any
medical or paramedical examination which is part of the initial
requirements for this application;
(b) The date of this receipt; or
(c) The policy date as specified in Part I of the application.
However, where the temporary coverage under this receipt replaces temporary
coverage with respect to the same policy under another receipt given for a
payment previously made, the temporary coverage under this receipt begins as
of the same date that the replaced temporary coverage began.
5. COVERAGE TERMINATES - 90 DAY MAXIMUM. The temporary coverage will terminate
on the EARLIEST of the following dates:
(a) The ninetieth day following the date coverage begins under this receipt;
(b) The fifth day after we mail to the Applicant(s) notice that the
application has been declined:
(c) The date the Applicant(s) makes written request for a full refund of the
payment, in which event all coverage will be void from the start;
(d) The date the policy is put into force. If and when the policy is put in
force, it will replace the temporary coverage under this receipt. In the
event, we shall have no liability because of the temporary coverage. this
case, the liability shall only be as provided under the policy.
6. REFUND OF PAYMENT.
(a) If no claim for benefits arises under the temporary coverage, a full
refund of the payment made with respect to the policy will be made, if:
(i) we decline the application; or
(ii) a written request for the refund is made not later than 10 days
after delivery of the policy (20 days for a Variable Adjustable
Life or when required).
(b) If a claim for benefits arises under the temporary coverage, a refund
will be made of an appropriate part of the payment made with respect to
the policy, if:
(i) we decline the application; or
(ii) our liability on account of the temporary coverage is, because of
paragraph 3, less than it would have been under the policy.
7. LIMITATION ON AUTHORITY. No agent or medical examiner has any right accept
risks, make or change contracts, give up any of our rights or requirements,
or change the provisions of this receipt.
<PAGE> 11
RF575101
NOT PART OF THE APPLICATION AGENT'S STATEMENT
--------------------------------------------------------------------------------
SECTION A -- ANSWER FOR ALL CASES.
--------------------------------------------------------------------------------
<TABLE>
<S> <C> <C> <C>
1. If cash was collected, did you give the receipt and explain that coverage is provided only as stated, and Yes No
that it is temporary and limited in amount? If "No", cash must be refunded. (If Applicant did not give cash,
then enter, in Q.21 name and address of person who did.) [] []
2. a. Did you ask each question in person, were answers recorded exactly as made to you (also see Section B),
and were all required signatures obtained in your presence? If "No", explain in Q. 21 [] []
b. Did every person signing this application communicate in English well enough to understand and answer
each question in English (including those on the Non-Medical Part II, if applicable)? [] []
C. If Q.2b is answered "No", answer all parts of Q. 2c.:
- Who acted as interpreter? Agent []; Other []
- If English was not used as the primary language, which language and/or dialect(s) was the sales
interview conducted in? [ ]
- For the purpose of completing any telephone inspection reports, the proposed insured can converse
comfortably in [ ]
3. If "Yes" to (a), (b) or (c) in Q.6 in the Application Part I, please provide details in Q. 21.
4. By reason of this transaction, is replacement involved? If "Yes", give details in Q. 21. [] []
</TABLE>
--------------------------------------------------------------------------------
5. (a) Proposed Insured's County of Residence? [ ]
(b) State where Applicant signed the application? [ ]
If Florida, county where signed? [ ]
Did the Applicant sign by mail? [] Yes [] No
(c) If Applicant not Insured, state where Insured signed the
application? [ ]
If Florida, county where signed? [ ]
Did the Insured sign by mail? [] Yes [] No
(d) If the Owner is not the applic or the Insured, state where Owner
signed the application? [ ]
If Florida, county where signed? [ ]
(e) State where the policy will be delivered? [ ]
If Florida, county of delivery? [ ]
Is the policy to be delivered by mail? [] Yes [] No
6. Estimated Annualized Premium? Check box if TAS agent []
$ [ ]
7. How well do you know the Primary Insured?
(check every box that applies).
(a) [] Approached by Proposed Insured
(b) [] Well, for [ ] years
(c) [] Casually [ ] years
(d) [] Referral from NYL Agent
(e) [] Met on solicitation
(f) [] Relative (relationship
[ ])
(g) [] Referral from existing Agent
<TABLE>
<S> <C>
8. Source? (a) [] My Client (b) [] Direct Mail (c) [] Group Contract
(d) [] Client Referral (e) [] Referral from other Advisor/Professional
(f) [] Seminar (g) [] Orphan Policyowner (h) [] Ad Reply
(i) [] Financial Planning client (j) [] Agent's Relative (k) [] Other
(RIA's only)
</TABLE>
---------------------------------------------------------------
ALWAYS ANSWER Q.9 - ADDITIONAL DETAILS IN Q.21
---------------------------------------------------------------
9. Market/Needs? Please indicate the Applicant's purpose for purchasing
(check only one; if purchase was made to serve multiple purposes, please
check the one that was primary).
A. Individual Purchase
<TABLE>
<S> <C>
(a) [] Retirement Planning (b) [] Estate Planning
(c) [] Income to Surviving Spouse (d) [] Pension Max
and or Children
(e) [] College Funding (f) [] Mortgage Protection
(g) [] Charitable Giving (h) [] Gift to Child/grandchild
(i) [] Other
-----------------------
</TABLE>
Approx. Household Income $ [ ] Approx. Net Worth [ ]
Spouse/Dependents(# of dependents/minors) Spouse [] Dependents#
--------
Age(s)
--------------
Homeowner? [] Yes [] No
Has Employer Sponsored Group Life Insurance or VPD coverage? [] Yes [] No
B. Employer Sponsored Purchase
<TABLE>
<S> <C>
(a) [] Key Employee (b) [] Deferred Comp. Salary continuation
(c) [] Split Dollar/Carve-out (d) [] Qualified Plan Sale (303, 401K, 457)
(e) [] Buy Sell/Stock Redemption (f) [] Bonus Plan
(g) [] Vol. Payroll Deduction (h) [] Other
------------------------------
</TABLE>
Approximate Net Worth of business [ ]
If Business, [] Public Co. or []Privately Owned # of employees
[ ]
--------------------------------------------------------------------------------
SECTION B -- ANSWER IF UNDERWRIT1NG REQUIRED
(I.E., WHEN PART I QUESTIONS 14-17 OR A PART II REQUIRED).
--------------------------------------------------------------------------------
NOTE: It is your responsibility, as the Agent in this case, to disclose
information that may affect the underwriting of this application, whether
or not such information may appear elsewhere in the application. This
includes information obtained after the application is completed.
10. Are you aware of any of the following underwriting factors (past, present
or contemplated) that apply to the person proposed for coverage?
<TABLE>
<CAPTION>
Yes No
<S> <C> <C>
(a) declination by any company? [] []
(b) physical or mental abnormality or handicap? [] []
(c) hospitalization, surgery, medical treatment, or counseling? [] []
(d) activities in a hazardous avocation or occupation? [] []
(e) use of tobacco or nicotine in last 5 years? [] []
(f) alcohol or drug abuse? [] []
(g) arrests, or driver's license suspension or revocation? [] []
(h) inaccurate weight and/or height reported to you? [] []
(i) foreign residence or travel? [] []
If "Yes" to any (a) -- (i), give details in Q. 21 or in a separate
letter.
(j) Med. Underwriting Rules Chart used? [] A, [] B, [] C, [] P for
prior insured, single sum, [] Sel Agt
</TABLE>
106 February 1999(S)
<PAGE> 12
<TABLE>
<S> <C>
------------------------------------------------------------------------------------------------------------------------------------
SECTION C-ALWAYS ANSWER Q. 12 IF THE SUM OF LIFE INSURANCE IN FORCE AND APPLIED FOR ON PROPOSED INSURED IS $50,000 OR MORE, ANSWER
Q.11 AND Q.13.
------------------------------------------------------------------------------------------------------------------------------------
Total With WP ADB Amount
11. Life insurance in force on Proposed Insured (If none, enter "0")
--------------- ---------------- -------------------
In New York Life, with: Personal Beneficiary (a) $ (b) $ (c) $
(incl. subsidiaries) --------------- ---------------- -------------------
--------------- ---------------- -------------------
Business Beneficiary (d) $ (e) $ (f) $
--------------- ---------------- -------------------
--------------- ---------------- -------------------
In other companies, with: Personal Beneficiary (g) $ (h) $ (i) $
--------------- ---------------- -------------------
--------------- ---------------- -------------------
Business Beneficiary (j) $ (k) $ (l) $
--------------- ---------------- -------------------
12. Estimated net worth and income: (If none. enter "0") Net Worth Annual Earned Income Annual Unearned Income
--------------- ---------------- -------------------
Proposed Insured (a) $ (b) $ (c) $
--------------- ---------------- -------------------
--------------- ---------------- -------------------
Owner (if not Proposed Insured) (d) $ (e) $ (f) $
--------------- ---------------- -------------------
13. Insurance on Others? In Q. 21, give names, relationships and amounts of business or personal insurance to be applied for
(use "A"), pending (use "P") and in force (use "F") on (a) other members of business (e.g., key employees, partners,
shareholders) or (b) other family members.
------------------------------------------------------------------------------------------------------------------------------------
SECTION D-ANSWER IF POLICY TO BE ADDED TO EXISTING PLAN OR ARRANGEMENT OR IF NYL-A-PLAN TYPE OR GOV'T ALLOT. MODE APPLIED FOR.
------------------------------------------------------------------------------------------------------------------------------------
14. Arrangement No. (incl. C-O-M, Nyl-A-Plan, Nyl-A-Plus, KPA, PTA, TSA PAY POINT [ ][ ][ ][ ]
(b) [ ] 17916 Type [ ] Nyl-A-Plan (N)[ ] Nyl-A-Plus (S)
[ ] TSA/STEP (T)
15. (a) Nyl-A-Plan or Nyl-A-Plus Name
16. Tax-Qualified Plan: Name
17. Gov't Allot (a) Mil. Service Branch (b) Pay Grade (c) Soc Sec (Ins.) No. of Allotter --
------------------------------------------------------------------------------------------------------------------------------------
SECTION E - ANSWER IF TRUSTEE IS APPLICANT, OWNER, SUCCESSOR OWNER, OR PAYOR.
------------------------------------------------------------------------------------------------------------------------------------
18. Date of Trust 20. Certified copy of Trust (and last amendment, if any) or Form 20885
19. Date of last amendment, if any [ ] has been or will be forwarded [ ] furnished with Policy No.
------------------------------------------------------------------------------------------------------------------------------------
21. Remarks, Additional Details
---------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
I DECLARE THAT: (a) the application was secured by me personally, and that I have no understanding or agreement with any other
person, directly or indirectly, as to commissions or compensation on any policy applied for, except as may be specified below, and
(b) I have not paid or allowed, and I agree that I will not hereafter pay or allow, either directly or indirectly, any compensation
or commission other than below, or any rebate of premium in any manner whatsoever to the Applicant or to any other person.
------------------------------------------
I HEREWITH SUBMIT the cash collected with this application. Date
"OFFICE"
Share% Code No. Surname Date Received
Any other person(s) sharing commission Signature Stamp Here
Share% Code No. Surname Sign below
------------------------------------------
106 February 1999 (S)
</TABLE>
<PAGE> 13
[NEW YORK LIFE LOGO]
NEW YORK LIFE INSURANCE COMPANY
NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION (A DELAWARE CORPORATION)
51 MADISON AVENUE NEW YORK, NY 10010
NYLIFE INSURANCE COMPANY OF ARIZONA (NOT LICENSED IN EVERY STATE)
2398 E. CAMELBACK ROAD, SUITE 500 PHOENIX, AZ 85016
===============================================================================
CHECK-O-MATIC (C-O-M) ARRANGEMENT TERMS
(BASE PLAN AND/OR OPTION TO PURCHASE PAID-UP ADDITIONS RIDER):
1. New York Life Insurance Company or New York Life Insurance and Annuity
Corporation or NYLIFE Insurance Company of Arizona, as indicated below,
will direct the transfer of funds from the account you have designated.
This transfer will be used to pay premiums on the policy (policies) and/or
monthly Option to Purchase Paid-up Additions (OPP) premiums as shown
below. This will be done each month under a regular schedule established
by us. We will not send premium notices while this arrangement is in
effect.
2. This arrangement does not change the premium due dates specified in the
policy and it does not extend any of the grace periods for paying these
premiums. The policy or policies will lapse at the end of the grace or
late period if the premium remains unpaid.
3. Any policy included under this arrangement is subject to our minimum and
maximum premium and OPP premium rules.
4. For in-force policies the arrangement will apply to the policies shown
below and will cover all future premiums and any current premiums that
have not yet been paid.
PLEASE DETACH AND COMPLETE THIS FORM.
PLEASE REFER TO PAGE 2 FOR INSTRUCTIONS AND TO REPORT A CHANGE OF ADDRESS.
-------------------------------------------------------------------------------
CHECK-O-MATIC (C-O-M) REQUEST FORM
A. SELECT APPLICABLE INSURER (select only one): [ ] New York Life Insurance
Company OR [ ] New York Life Insurance and Annuity Corporation OR [ ] NYLIFE
Insurance Company of Arizona
-------------------------------------------------------------------------------
<TABLE>
<S> <C> <C> <C> <C>
B. POLICY INFORMATION:
1. CHECK [ ] Single C-O-M [ ] Multiple C-O-M [ ] Add to C-O-M [ ] C-O-M OPP [ ] OPP Level Change [ ] Account Change
2. ENTER NAME OF (PROPOSED) INSURED/ANNUITANT, POLICY NO. AND C-O-M INFORMATION IF APPLICABLE:
Name of (Proposed) Insured/Annuitant Policy No. C-O-M C-O-M OPP If Adding To An
Premium Premium Inforce C-O-M,
Provide Case Ref.
No. or Pol. No.(s)
----------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------
======================================================================================================================
</TABLE>
C. AUTHORIZATION:
I understand that I may stop this payment arrangement by giving written notice
to the Insurer. The owner of each policy may stop it for his or her own policy.
The arrangement ends on the day the Insurer receives the notice.
I (we) authorize New York Life Insurance Company or one of its subsidiaries to
make monthly withdrawals from the account named below. I (we) also authorize
the Financial Organization shown on the ENCLOSED SAMPLE CHECK OR PAYMENT CHECK,
to debit my (our) account accordingly.
NAME AND ADDRESS OF FINANCIAL ORGANIZATION
-------------------------------------
-------------------------------------------------------------------------------
NAME OF DEPOSITOR(S) SIGNATURE OF DEPOSITOR(S)
as shown on as shown on
Financial (1) Financial X
----------------------- ------------------------
Organization's Organization's
records records or other
(Please Print) (2) Authorized X
----------------------- ------------------------
Signature
DATE
--------------------
<PAGE> 14
INSTRUCTIONS
-------------------------------------------------------------------------------
IMPORTANT:
1) NEW YORK LIFE INSURANCE COMPANY, NEW YORK LIFE INSURANCE AND ANNUITY
CORPORATION (NYLIAC) AND NYLIFE INSURANCE COMPANY OF ARIZONA POLICIES
CANNOT BE INCLUDED TOGETHER IN THE SAME CHECK-O-MATIC ARRANGEMENT. USE A
SEPARATE REQUEST FORM FOR EACH INSURER.
2) NYLIAC LIFE INSURANCE POLICIES AND NYLIAC ANNIUTY POLICIES ALSO CANNOT BE
INCLUDED IN THE SAME NYLIAC CHECK-O-MATIC ARRANGEMENT.
-------------------------------------------------------------------------------
1. IN SECTION A. (SELECT APPLICABLE INSURER), please indicate: New York Life
Insurance Company OR New York Life Insurance and Annuity Corporation OR
NYLIFE Insurance Company of Arizona C-O-M arrangement.
2. IN SECTION B. (POLICY INFORMATION), please always print the name of the
(Proposed) Insured/Annuitant and the policy no. Also fill in any other
applicable parts of this section. If other policies exist on this
arrangement, agents please provide the case reference number or policy
number(s).
3. PLEASE COMPLETE SECTION C. (AUTHORIZATION) IF:
a) you are authorizing the establishment of a new C-O-M arrangement under
a checking account which is not now being used for this purpose, or
b) you are authorizing the establishment of, or changing the level of, an
OPP C-O-M arrangement under a checking account which is not being used
for this purpose, or
c) you are changing financial organizations, branches or accounts.
4. PLEASE INCLUDE A SAMPLE CHECK MARKED VOID UNLESS:
a) The policy is being added to an existing C-O-M arrangement with the
same Insurer and there is no change in the account being used, or
b) the policy to which the OPP Rider is attached is already on a C-O-M
arrangement, or
c) payment is being made by check on the account to be used for the
arrangement and the check accompanies this form.
-------------------------------------------------------------------------------
THANK YOU FOR CHOOSING CHECK-O-MATIC,
THE MOST EFFICIENT WAY TO PAY YOUR PREMIUMS.
-------------------------------------------------------------------------------
