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[LOGO OF AMERICAN LEGACY III(R)] Lincoln Life & Annuity
Company of New York
Home office Syracuse, New York
Applicants signing in New York must use this form.
American Legacy III C Share
Variable Annuity Application
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Instructions: Please type or print. ANY ALTERATIONS TO THIS APPLICATION MUST BE
INITIALED BY THE CONTRACT OWNER.
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1a Contract Owner
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Full legal name or trust name*
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Street address
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City State ZIP
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Trustee name*
Note: Maximum age of Contract Owner is 89.
Social Security number/TIN [_][_][_]-[_][_]-[_][_][_][_]
Date of birth [_][_]-[_][_]-[_][_] [_] Male [_]Female
Month Day Year
Home telephone number [_][_][_] [_][_][_]-[_][_][_][_]
Date of trust* [_][_] [_][_] [_][_] Is trust revocable?*
Month Day Year [_] Yes [_] No
*This information is required for trusts.
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1b Joint Contract Owner
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Full legal name
Note: Maximum age of Joint Contract Owner is 89.
Social Security number [_][_][_]-[_][_]-[_][_][_][_]
Date of birth [_][_]-[_][_]-[_][_] [_] Male [_] Female
Month Day Year
[_] Spouse [_] Non-Spouse
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2a Annuitant (If no Annuitant is specified, the Contract 5/22/00 Owner, or Joint
Owner if younger, will be the Annuitant.)
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Full legal name or trust name*
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Street address
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City State ZIP
Note: Maximum age of Contract Owner is 89.
Social Security number/TIN [_][_][_]-[_][_]-[_][_][_][_]
Date of birth [_][_]-[_][_]-[_][_] [_] Male [_]Female
Month Day Year
Home telephone number [_][_][_] [_][_][_]-[_][_][_][_]
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2b Contingent Annuitant
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Full legal name
Social Security number [_][_][_]-[_][_]-[_][_][_][_]
Note: Maximum age of Contingent Annuitant is 89.
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3 Beneficiary(ies) Of Contract Owner (List additional beneficiaries on a
separate sheet. If listing children, use full legal names.)
<TABLE>
<CAPTION>
<S> <C> <C> <C>
%
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Full legal name or trust name* [_] Primary [_] Contingent Relationship to Contract Owner SSN/TIN
%
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Full legal name or trust name* [_] Primary [_] Contingent Relationship to Contract Owner SSN/TIN
%
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Full legal name or trust name* [_] Primary [_] Contingent Relationship to Contract Owner SSN/TIN
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Executor/Trustee name*
</TABLE>
Date of trust* [_][_] [_][_] [_][_] Is trust revocable?*
Month Day Year [_] Yes [_] No
*This information is required for trusts.
To specify an annuity payment option for your beneficiary, please complete the
Beneficiary Payment Options form (29953AL-NY).
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4 Type Of American Legacy Contract
Nonqualified: [_] Initial Contribution OR [_] 1035 Exchange
Tax-Qualified (must complete plan type):
[_] Initial Contribution, Tax Year ______ OR
[_] Transfer OR [_] Rollover
Plan Type (check one): [_] Roth IRA [_] Traditional IRA
[_] Non-ERISA403(b)* (transfers only)
*Indicate plan year-end: [_][_] [_][_]
Month Day
Litho in USALL/LL/4632
(C)2000 American Funds Distributors, Inc.
Form 28617-CNY 0400 Lit. No. LEG3CAP-001-0700
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5a Allocation (This section must be completed.)
Initial minimum: $25,000
Future contributions will follow the allocation below. If DCA option is
selected, the entire amount of each future contribution will follow the
allocation in Section 5b.
If no allocations are specified in Section 5a or 5b, the entire amount will be
allocated to the Cash Management Fund pending instructions from the Contract
Owner.
Please allocate my contribution of:
$ OR $
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Initial contribution Approximate amount
from previous carrier
INTO THE FUND(S) BELOW
Use whole percentages
% Global Growth Fund
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% Global Small Capitalization Fund
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% Growth Fund
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% International Fund
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% New World Fund
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% Growth-Income Fund
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% Asset Allocation Fund
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% High-Yield Bond Fund
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% Bond Fund
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% U.S. Govt./AAA-Rated Securities Fund
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% Cash Management Fund
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% DCA Fixed Account (must complete 5b)
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% Total (must = 100%)
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5b Dollar Cost Averaging (Complete only if electing DCA.)
$1,500 minimum required in the Holding Account
Total amount to DCA: $
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OR
MONTHLY amount to DCA: $
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OVER THE FOLLOWING PERIOD:
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MONTHS (6-60)
FROM THE FOLLOWING HOLDING ACCOUNT (check one):
[_] DCA Fixed Account
[_] Cash Management Fund*
[_] U.S. Govt./AAA-Rated Securities Fund*
INTO THE FUND(S) BELOW
Use whole percentages *The DCA Holding Account
and the DCA fund elected
cannot be the same.
% Global Growth Fund
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% Global Small Capitalization Fund
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% Growth Fund
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% International Fund
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% New World Fund
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% Growth-Income Fund
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% Asset Allocation Fund
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% High-Yield Bond Fund
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% Bond Fund
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% U.S. Govt./AAA-Rated Securities Fund
------------
% Cash Management Fund
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% Total (must = 100%)
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Future contributions will not automatically start a new DCA program.
Instructions must accompany each DCA contribution.
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5c Cross-Reinvestment Or Portfolio Rebalancing
To elect either of these options, please complete the Cross-Reinvestment form
(28051AL-NY) or the Portfolio Rebalancing form (28887AL-NY).
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6 Automatic Withdrawals
[_] Please provide me with automatic withdrawals totaling _______ % of total
contract value or $ _________________ payable as follows:
($50 minimum)
[_] Monthly [_] Quarterly [_] Semiannually [_] Annually
Begin withdrawals in [_][_] [_][_]
Month Year
ELECT ONE: [_] Do withhold taxes
Amount to be withheld $________________ OR ________ %
[_] Do not withhold taxes
ELECT ONE: [_] Send check to address of record
OR
[_] Send check to the following alternate address:
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[_] Direct deposit
For direct deposit into your bank account, the
Electronic Fund Transfer Authorization form
(27326AL-NY) must be completed and submitted
with a voided check or a savings deposit slip.
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7 Automatic Bank Draft
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Print account holder name(s) EXACTLY as shown on bank records
ATTACH VOIDED CHECK
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Bank name ABA number
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Bank street address City State ZIP
Automatic bank draft start date: [_][_] [_][_] [_][_]
Month Day (1-28) Year
$
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Checking account number Monthly amount
I/We hereby request and authorize you to pay and charge to my/our account checks
or electronic fund transfer debits processed by and payable to the order of
Lincoln Life & Annuity Company of New York & Annuity Company of New York, P.O.
Box 2348, Fort Wayne, IN 46801-2348, provided there are sufficient collected
funds in said account to pay the same upon presentation. It will not be
necessary for any officer or employee of Lincoln Life & Annuity Company of New
York & Annuity Company of New York to sign such checks. I/We agree that your
rights in respect to each such check shall be the same as if it were a check
drawn on you and signed personally by me/us. This authority is to remain in
effect until revoked by me/us, and until you actually receive such notice I/we
agree that you shall be fully protected in honoring any such check or electronic
fund transfer debit. I/We further agree that if any such check or electronic
fund transfer debit be dishonored, whether with or without cause and whether
intentionally or inadvertently, you shall be under no liability whatsoever even
though such dishonor results in the forfeiture of insurance or investment loss
to me/us.
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8 Replacement Will the proposed contract replace any existing annuity or life
insurance contract?
ELECT ONE: [_] No [_] Yes If yes, complete the 1035 Exchange or
Qualified Retirement Account Transfer form.
(Attach a state replacement form.)
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Company name
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Plan name Year issued
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9 Signatures
All statements made in this application are true to the best of my/our knowledge
and belief, and I/we agree to all terms and conditions as shown. I/We
acknowledge receipt of current prospectuses for American Legacy III C Share and
American Funds Insurance Series(SM) and verify my/our understanding that all
payments and values provided by the contract, when based on investment
experience of the funds in the Series, are variable and not guaranteed as to
dollar amount. Under penalty of perjury, the Contract Owner(s) certifies that
the Social Security (or taxpayer identification) number(s) is correct as it
appears in this application.
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Signed at (city) State
Date [_][_] [_][_] [_][_]
Month Day Year
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Signature of Contract Owner Joint Contract Owner (if applicable)
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Signed at (city) State
Date [_][_] [_][_] [_][_]
Month Day Year
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Signature of Annuitant (Annuitant must sign if Contract Owner is a trust or
custodian.)
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FINANCIAL ADVISER MUST COMPLETE REVERSE SIDE (PAGE 4)
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THE FOLLOWING SECTIONS MUST BE COMPLETED BY THE FINANCIAL ADVISER OR SECURITIES
DEALER. Please type or print.
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10 Insurance In Force Will the proposed contract replace any existing annuity
or life insurance contract?
ELECT ONE: [_] No [_] Yes If yes, please list the insurance in force on
the life of the proposed Contract Owner(s)
and Annuitant(s):
(Attach a state replacement form.)
$
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Company name Year issued Amount
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11 Additional Remarks
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12 Dealer Information Note: Licensing appointment with Lincoln Life &
Annuity Company of New York is required for this
application to be processed. If more than one
representative, please indicate names and percentages in
Section 11.
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Registered representative's name (print as it appears on NASD licensing)
Registered representative's telephone number [_][_][_] [_][_][_]-[_][_][_][_]
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Client account number at dealer (if applicable) 5/22/00
Registered representative's SSN [_][_][_]-[_][_]-[_][_][_][_]
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Dealer's name
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Branch address City State ZIP
[_] CHECK IF BROKER CHANGE OF ADDRESS
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13 Representative's Signature
The representative hereby certifies that he/she witnessed the signature(s) in
section 9 and that all information contained in this application is true to the
best of his/her knowledge and belief.
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Signature
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Send completed application -- with a check made payable to Lincoln Life &
Annuity Company of New York -- to your investment dealer's home office or to:
[LOGO OF AMERICAN LEGACY III(R)]
<TABLE>
<S> <C>
By Express Mail:
Lincoln Life & Annuity Company of New York Lincoln Life & Annuity Company of New York
Servicing Office - P.O. Box 2348 Attention: American Legacy Operations
Fort Wayne, IN 46801-2348 1300 South Clinton Street
Fort Wayne, IN 46802
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If you have any questions regarding this application, please call Lincoln Life &
Annuity Company of New York at 800 942-5500.
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