MORGAN STANLEY DEAN WITTER VA3
FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY
ISSUED BY: ALLSTATE LIFE INSURANCE COMPANY OF NEW YORK
PO Box 94038, Palatine, IL 60094-4038 Telephone: 1-800-256-9392
Overnight Address: 3100 Sanders Rd., M4A, Northbrook, IL 60062
OWNER(S)
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Name _______________________ // M // F Birthdate ___/__/____
Address______________________________________ Soc. Sec. No. ____-____-____
City State Zip
Name _______________________ // M // F Birthdate ___/__/____
Address______________________________________ Soc. Sec. No. ____-____-____
City State Zip
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ANNUITANT
Leave blank if Annuitant is the same as sole Owner; otherwise complete.
Name _______________________ // M // F Birthdate ___/__/____
Address______________________________________ Soc. Sec. No. ____-____-____
City State Zip
Relationship to Owner ______________________________
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BENEFICIARY(IES)
Name ___________________________ Relationship to Owner ___________________
Name ___________________________ Relationship to Owner ___________________
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PURCHASE PAYMENT/ Total Purchase Payment $ _______
PLAN OPTIONS
PORTFOLIO SELECTION MSAM FUNDS
AIM Variable Insurance Funds //Equity Growth ____%
//Aggressive Growth ___% //International Magnum ____%
//Blue Chip ___% //Emerging Markets Equity ____%
//Capital Appreciation ___% //U.S. Real Estate ____%
//Growth ___% //Mid-Cap Value ____%
//Value ___% Putnam Variable Trust
Alliance Variable Produce Series Funds //Growth & Income ____%
//Growth ___% //International Growth ____%
//Growth & Income ___% //International New Opportunities ____%
//Premium Growth ___% //New Opportunities ____%
MSDW Variable Investment Series //OTC & Emerging Growth ____%
//Money Market ___% //Voyager ____%
//Quality Income Plus ___% Van Kampen Life Investment Trust
//High Yield ___% //Emerging Growth ____%
//Utilities ___% Fixed Account
//Income Builder ___% //DCA Fixed Account ____%
//Dividend Growth ___% // ___________ ____%
//Capital Growth ___% // ___________ ____%
//Global Div. Growth ___% Total 100%
//European Growth ___% Plan Options (Choose one. If none is
//Equity ___% selected, base policy will apply):
//S&P 500 Index ___% //Performance Death Benefit Option
//Competitive Edge ___% (Highest Anniversary Value)s
//Strategist ___%
//Aggressive Equity ___%
//Short-Term Bond ___%
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REPLACEMENT
INFORMATION
Will this annuity replace or change any existing annuity or life insurance?
// Yes // No (If Yes, complete the following.)
Company ________________________ Policy No. ________________________
Cost basis amount ______________ Policy Date _______________________
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TAX QUALIFIED PLAN
// Yes // No (If Yes, complete the following.)
// Traditional IRA // Roth IRA // SEP // Other ______
// Rollover // 401(a) (pension)
// Transfer // 403(b) (TSA)
// Contribution $ _______ Contribution Year ____________
(attach Form 5305 for SEP)
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SPECIAL INSTRUCTIONS
____________________________________________________________________________
____________________________________________________________________________
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SIGNATURE(S)
(contract applications and certificate enrollments are referred to as
applications.)
A copy of this application signed by the Financial Advisor will be the receipt
for the first purchase payment. If Allstate Life Insurance Company of New York
("Allstate Life") declines this application, Allstate Life will have not
liability except to return the first purchase payment.
I have read the above statements and represent that they are complete and
true to the best of my knowledge and belief. I agree that this application
shall be a part of the annuity issued by Allstate Life. By accepting the
annuity issued, I agree to any additions or corrections to this
application. Allstate Life will obtain written agreement from me for any
change in the benefits, type of plan, or birthdates.
I understand that annuity values and income payments based on the investment
experience of a separate account are variable and not guaranteed as to dollar
amount. I acknowledge receipt of the current prospectus for the Flexible
Premium Deferred Variable Annuity.
Signed at ________________________________________ Date ___/___/___
City State
Owner(s) ___________________________________________________________
Annuitant __________________________________________________________
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REPRESENTATIVE
USE ONLY
Will the annuity applied for replace or change any existing annuity or life
insurance? // Yes // No
Rep Name (Please print) ________________________ Phone No. ( ) ___-____
Rep Signature __________________________________ Branch/Rep No. ____________
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