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EXHIBIT (5)
Variable Annuity Application
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GE Capital Life Assurance Company of New York
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Plan Information
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Annuity Name: [FLEXIBLE PREMIUM VARIABLE DEFERRED ANNUITY]
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Premium Payment: Minimum Payment: For 1035 Exchange(s) or Transfer(s)
$5,000.00 and/or estimated premium $
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Complete Section A or B.
Section A: Non-Qualified (Check all that apply) Section B: Qualified (Check all that apply)
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[X] New purchase [ ] Traditional IRA [ ] Custodial IRA [ ] ROTH IRA
[ ] 1035 Exchange(s) [ ] TSA 403(b) [ ] SEP [ ] Other_____________
[ ] Transfer [ ] Rollover [ ] Direct Rollover
[ ] New Contribution for tax year____________
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Riders (Check availability)
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Please print name of rider. See prospectus for age availability.
[ ]
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[ ]
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Owner (Name or name of trust and trustee)
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(Last, First, M.) Gender
[ ] DOE JOHN (NMI) [X] M [ ] F
Date of birth or trust date (mm-dd-yyyy) Social Security no. or Tax ID Telephone no.
03 - 01 - 1965 123456789 800 - 555 - 1212
Address
123 MAIN ST
City State Zip code
ANYTOWN NY 00000
Joint Owner (Optional): Name (Last, First, M.) Gender
________________________________________________ [ ] M [ ]F
Date of birth (mm-dd-yyyy) Social Security no. or Tax ID Telephone no.
_____ - ______- ____________ _____________________________ ______-______-________
Address
________________________________________________________________________________________________
City State Zip code
________________________________________________ _________ _________
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Annuitant (if other than Owner)
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(Last, First, M.) Gender
_______________________________________________ [ ] M [ ] F
Date of birth (mm-dd-yyyy) Social Security no. or Tax ID Telephone no.
_____ - ______- ____________ _____________________________ _____-_____-____
Address
________________________________________________________________________________________________
City State Zip code
________________________________________________ _________ _________
Joint Annuitant: Name (Last, First, M.): Gender
________________________________________________ [ ] M [ ]F
Date of birth (mm-dd-yyyy) Social Security no. or Tax ID Telephone no.
_____ - ______- ____________ _____________________________ ______-______-________
Address
________________________________________________________________________________________________
City State Zip code
________________________________________________ _________ _________
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Regular Mail For Inquiries and/or Questions Overnight Delivery
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GE Capital Life Assurance Company of New York Internet: www.gefinancialassurance.com GE Capital Life Assurance Company of New York
Attn: Annuity New Business Toll Free:(800) 313-5282 Attn: Annuity New Business
P.O. Box 85093 6610 W. Broad Street
Richmond, VA 23285-5093 Richmond, VA 23230
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Variable Annuity Application
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GE Capital Life Assurance Company of New York
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Beneficiary (Name or name of trust and trustee)
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(Last, First, M.) Allocated [X] Primary
[ ] DOE JANE (NMI) 100% [ ] Contingent
Date of birth or trust date (mm-dd-yyyy) Relationship to the Owner Gender
03 - 15 - 1965 Spouse [ ] M [X] F
Address Telephone no.
123 MAIN ST 800 - 555 - 1212
City State Zip code
ANYTOWN NY 00000
Beneficiary: Name (Last, First, M.) Allocated [ ] Primary
_________________________________________________________ _____% [ ] Contingent
Date of birth or trust date (mm-dd-yyyy) Relationship to the Owner Gender
______- _______-_______________________ __________________________ [ ] M [ ] F
Address Telephone no.
______________________________________________________________________________ ____-_____-_____
City State Zip code
________________________________________________ _______ ________________
Beneficiary: Name (Last, First, M.) Allocated [ ] Primary
_________________________________________________________ _____% [ ] Contingent
Date of birth or trust date (mm-dd-yyyy) Relationship to the Owner Gender
______- _______-_______________________ __________________________ [ ] M [ ] F
Address Telephone no.
______________________________________________________________________________ ____-_____-_____
City State Zip code
________________________________________________ _______ ________________
Beneficiary: Name (Last, First, M.) Allocated [ ] Primary
_________________________________________________________ _____% [ ] Contingent
Date of birth or trust date (mm-dd-yyyy) Relationship to the Owner Gender
______- _______-_______________________ __________________________ [ ] M [ ] F
Address Telephone no.
______________________________________________________________________________ ____-_____-_____
City State Zip code
________________________________________________ _______ ________________
Beneficiaries may be changed at any time by the Owner unless made irrevocable by checking this circle. [ ]
Regular Mail For Inquiries and/or Questions Overnight Delivery
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GE Capital Life Assurance Company of New York Internet: www.gefinancialassurance.com GE Capital Life Assurance Company of New York
Attn: Annuity New Business Toll Free:(800) 313-5282 Attn: Annuity New Business
P.O. Box 85093 6610 W. Broad Street
Richmond, VA 23285-5093 Richmond, VA 23230
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Variable Annuity Application
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GE Capital Life Assurance Company of New York
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Owner Signature(s) PLEASE READ CAREFULLY
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Will the proposed annuity replace any existing annuity or insurance contract?
[ ] Yes [x] No
All statements made in this application are true to the best of my/our knowledge
and belief, and the answers to these questions, together with this agreement,
are the basis for issuing the contract. I/we agree to all terms and conditions
as shown. I/we further agree that this application shall be a part of the
annuity contract, and verify our understanding that ALL PAYMENTS AND VALUES
PROVIDED BY THE CONTRACT, WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE
SEPARATE ACCOUNT, ARE VARIABLE AND NOT GUARANTEED AS TO DOLLAR AMOUNT. THE
OWNER ACKNOWLEDGES RECEIPT OF PROSPECTUSES FOR THE SEPARATE ACCOUNT AND ALL
PORTFOLIOS APPLICABLE TO THE CONTRACT AND APPLICABLE SUPPLEMENTS DATED WITHIN
13 MONTHS OF THIS APPLICATION. I/we agree that no one, except the President,
or a Vice President of the Company can make or change any annuity.
1. Have you received prospectuses dated within 13 months of this application
for the Separate Account and all funds applicable to the applied for contract?
[x] Yes [ ]No
2. Do you understand that the Contract Value may increase or decrease depending
on the investment return of the Subaccounts? [x] Yes [ ] No
3. Do you believe this contract will meet your insurance needs and financial
objectives? [x] Yes [ ] No
(Under penalties of perjury, I certify that: 1: The number shown on this form
is my correct taxpayer identification number (or I am waiting for a number to
be issued to me), 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
Internal Revenue Service (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. You must cross
out item 2 above if you have been notified by the IRS that you are currently
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.)
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Owner (sign as Trustee if Owner is a Trust) Joint Owner Date of signature (mm-dd-yy)
/s/ John Doe 04-01-2000
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Annuitant (required if other than Owner) City State
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Representative(s) Information and Signature(s)
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Do you have reason to believe that the proposed annuity will replace any
existing annuity or insurance contract? [ ] Yes [X] No If yes, submit completed
replacement form, where required. By signing, you certify that you have
witnessed the above signature(s) and that all information contained
in this application is true to the best of your knowledge and belief.
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Registered Representative Signature Print name (Last, First, M.)
/s/ Bill Smith SMITH BILL
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Representative S.S. no. Broker/Dealer name/branch# Client account no.
987654321 SMITH AGENCY 010101
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Address Telephone no
345 Broad St. 800-333-4444
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City State Zip code
Anytown NY 00000
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Registered Representative Signature Print name (Last, First, M.)
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Representative S.S. no. Telephone no.
- - [ ] A [ ] B
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Regular Mail For Inquiries and/or Questions Overnight Delivery
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GE Capital Life Assurance Company of New York Internet: www.gefinancialassurance.com GE Capital Life Assurance Company of New York
Attn: Annuity New Business Toll free: (800) 313-5282 Attn: Annuity New Business
P.O. Box 85093 6610 West Broad Street
Richmond, VA 23285-5093 Richmond, VA 23230
15351NY 4/2000 GE Capital Life Assurance Company of New York
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Variable Annuity Application
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GE Capital Life Assurance Company of New York
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Dollar-Cost Average (DCA) Option (will start 30 days after receipt of funds,
unless you specify an earlier date)
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(Optional) You may elect a series of automated scheduled transfers referred to
as Dollar-Cost Averaging (DCA). DCA is a method of transferring specified
amounts from one designated Subaccounts(s), or the Guarantee Account to any
other available Subaccounts(s), or the Guarantee Account on a monthly or
quarterly basis. Fund will remain in the DCA transfer accounts until the entire
account is depleted. DCA is available for initial premium, additional premium or
transfer from other Subaccounts. This option provides regular level investments
over a period of time. DCA is subject to the provisions of the contract. We
reserve the right to discontinue DCA upon 30 days written notice to you.
Under our Enhanced Dollar Cost Averaging Program, your entire premium must be
initially allocated to the Enhanced Dollar Cost Averaging Account where it will
be credited with interest at the guarantee interest rate in effect on the
transaction date. Each month, we will transfer amounts out of the Enhanced
Dollar Cost Averaging Account into the Subaccounts you selected. All amounts
will be transferred out by the end of the first six or twelve months,
whichever is applicable. Thereafter, only additional premiums may be allocated
to the Enhanced Dollar Cost Averaging Account under your contract. The interest
credited to amounts allocated to the Enhanced Dollar Cost Averaging Account
will exceed our actual earnings on supporting assets, less appropriate risk
and expense adjustments. We will recover amounts credited over amounts earned
from the existing charges described in your contract. Your contract charges
will not increase as a result of electing the Enhanced Dollar Cost Averaging
Program.
Transfer dollar amount of $ __________________ from: (Select one)
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[ ] Money Market Subaccount [ ] One year Guarantee Account [ ] Enhanced Rate Guarantee Account (Requires DCA)
Deplete account [ ] Yes [ ] No (Minimum 10 months) [ ] 12 Month
Stop date, if desired (mm-dd-yyyy) [ ] 6 Month
_______ - ________ -___________
to the following Subaccounts based on the frequency indicated: [ ] Monthly [ ] Quarterly
Percentage Transfer to Subaccounts: Percentage Transfer to Subaccounts:
__________% _____________________________________ __________% _________________________
__________% _____________________________________ __________% _________________________
__________% _____________________________________ __________% _________________________
__________% _____________________________________ __________% _________________________
__________% _____________________________________ __________% _________________________
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I/we understand that the Contract Value in my elected Subaccount must be kept
at or above the amount which will permit the dollar-cost averaging transfers
requested; otherwise these transfers will end. This request is in lieu of the
requirement for individual written transfer requests. I/we may also change
or terminate these transfers by written notice to GE Capital Life Assurance
Company of New York.
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Interest Sweep (Optional)
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On a periodic basis, we will transfer all interest earned during the prior
period only in the Guarantee Account, one and six year accounts whichever is
applicable, to the Subaccounts. The amount transferred will be allocated to the
Subaccounts according to the most recent allocation instructions. This will not
count as a transfer for purposes of determining a transfer charge or restricting
the amount of transfers. [ ] Quarterly [ ] Semi-annually [ ] Annually
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Rebalancing (Optional)
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Once you have allocated your money among the Subaccounts, the performance
of each Subaccount may cause your allocation to shift. You may instruct us
to automatically rebalance, (on a quarterly, semi-annual, or annual basis) your
Contract Value among the Subaccounts to return to the percentages specified in
your allocation instructions. The program does not include allocations to the
Guarantee Account. Your percentage allocations must be in whole percentages.
[ ] Quarterly [ ] Semi-annually [ ] Annually
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Systematic Withdrawals (Optional)
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You may elect to receive a withdrawal of the Contract Value for each of one or
more contract year(s) in the form of systematic withdrawals. We will treat your
request for systematic withdrawals as a request for one withdrawal each contract
year, payable in equal installments over a 12 month period. The commencement
date may be no sooner than 30 days after the contract date. Each withdrawal
may not exceed 10% of the Contract Value on the effective date of the first
installment for that contract year. Systematic withdrawals end on the Annuity
Commencement Date. We reserve the right to discontinue systematic
withdrawals upon 30 days written notice to you.
I/we wish to start a series of withdrawals which will begin 30 days after
contract date unless a date is specified. [ ] Date _____- ______- _________
(mm-dd-yyyy)
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[ ] 10% of Contract Value Withdrawal frequency: Check one:
[ ] $ _____________________________________________ [ ] Monthly [ ] Semi-Annually [ ] Owner(s) subject to backup withholding
(Amount not to exceed 10% of Contract Value) [ ] Quarterly [ ] Annually [ ] Owner(s) not subject to backup withholding
[ ] _______% Of the Contract Value If you ARE NOT subject to backup
(Cannot exceed 10%) withholding, but wish to have Federal
Income Tax withheld, please check here [ ]
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OWNERS UNDER AGE 59 1/2. (Check ONLY if applicable; tax penalties may apply
to withdrawals.) [ ] The above referenced contract is an IRA or is issued
to a Qualified Retirement Plan, and these payments are part of a series
of substantially equal periodic payments as described in IRC section
72(t)(2)(a)(iv).
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15351NY 4/2000 GE Capital Life Assurance Company of New York
