<PAGE> 1
EXHIBIT (10)
MULTI LIFE
APPLICATION
PART I
NEW YORK LIFE INSURANCE COMPANY
NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION
NYLIFE INSURANCE COMPANY OF ARIZONA
[PHOTO]
998-500
<PAGE> 2
<TABLE>
<CAPTION>
------------------------------------------------------------------------------------------------------------------------------------
GENERAL REQUIREMENTS FOR VARIOUS TYPES OF REQUESTED ACTIONS
------------------------------------------------------------------------------------------------------------------------------------
ACTION REQUESTED ENTRY IN HEADING QUESTIONS REQUIRING ANSWER
------------------------------------------------------------------------------------------------------------------------------------
<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).
------------------------------------------------------------------------------------------------------------------------------------
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. ---------------------------
------------------------------------------------------------------------------------------------------------------------------------
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.
------------------------------------------------------------------------------------------------------------------------------------
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.
------------------------------------------------------------------------------------------------------------------------------------
Reinstatement Insert Policy Number and Within 6 mos. if underwriting required; Ques. 1, 8, 9, 12, 13, 14-
check "Reinstatement" Box 17."
------------------------------------------------------------------------------------------------------------------------------------
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 ."
----------------------
------------------------------------------------------------------------------------------------------------------------------------
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 ."
---------------------
------------------------------------------------------------------------------------------------------------------------------------
</TABLE>
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ADDITIONAL INFORMATION
--------------------------------------------------------------------------------
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.
--------------------------------------------------------------------------------
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.
--------------------------------------------------------------------------------
For amounts in excess of option amounts, see Agents' Manual. Section UND
VI.
--------------------------------------------------------------------------------
For additional coverage: Ques. 8, 12, 13. Also 14-17 if a Simplified
Underwriting case.*
--------------------------------------------------------------------------------
After 6 mos.: See Agents' Manual. Section UND VI.
--------------------------------------------------------------------------------
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.
--------------------------------------------------------------------------------
Simplified Und. or Appropriate Part II. See Agents' Manual, Section UND VI.
--------------------------------------------------------------------------------
*If a Part II is required, omit Questions 14-17.
--------------------------------------------------------------------------------
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
EXPLANATION OF CI STANDARD AND SPECIAL STANDARD DESIGNATIONS:
CI STANDARD FAMILY DESIGNATION:
Proceeds will be payable on death of Insured 1st to Children and 2nd to the
Insured's estate. Proceeds payable on death of child will be payable 1st to
Insured, 2nd to Children and 3rd to Child's estate.
<TABLE>
<S> <C>
CI SPECIAL STANDARD DESIGNATION: SCI STANDARD DESIGNATION:
Proceeds payable on death of Insured to 1st spouse, 2nd Children, 3rd Estate PROCEEDS PAYABLE ON DEATH ON INSURED TO 1ST
Proceeds payable on death of child to 1st Insured, 2nd Spouse of Insured, 3rd SPOUSE, 2ND CHILDREN, 3RD ESTATE
Children PROCEEDS PAYABLE ON DEATH OF SPOUSE TO 1ST
INSURED. 2ND CHILDREN
PROCEEDS PAYABLE ON DEATH OF CHILD TO 1ST
INSURED, 2ND SPOUSE, 3RD CHILDREN
</TABLE>
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
------------------------------------------------------------------------------------------------------------------------------------
Split Dollar: 1st ABS Corporation A
1st Mary Doe B spouse
------------------------------------------------------------------------------------------------------------------------------------
Other Covered Insureds:
Primary Insured: 1st Mary Doe spouse
Other Covered Insured: 1st John Doe spouse
------------------------------------------------------------------------------------------------------------------------------------
Creditors: 1st ABC Inc as its interests may appear
1st Balance to Mary Doe. spouse
------------------------------------------------------------------------------------------------------------------------------------
First to Die Rider for SWL:
FTD rider: 1st Survivor of marriage of John and Mary Doe
SWL: 1st Joel Smythe son
------------------------------------------------------------------------------------------------------------------------------------
Last Will And Testament: 1st United Bank of Missouri as trustee under will dated September 14,
1984
------------------------------------------------------------------------------------------------------------------------------------
*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>
NAMES AND ADDRESSES OF FOUR FRIENDS AND RELATIVES
1. 3.
------------------------------------ -------------------------------------
------------------------------------ -------------------------------------
2. 4.
------------------------------------ -------------------------------------
------------------------------------ -------------------------------------
<PAGE> 3
RA0181274
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>
--------------------------------------------------------------------------------
1. PERSON(S) PROPOSED FOR COVERAGE
--------------------------------------------------------------------------------
PRIMARY INSURED (PI)
--------------------------------------------------------------------------------
[] 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 | | | | | | | | | | | Birthplace
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
--------------------------------------------------------------------------------
OTHER INSURED 1
--------------------------------------------------------------------------------
[] OCI/5YTR [] Desig. Insd. - SPO [] 2nd Insd - SWL/SVUL
[] SCI Spouse* [] CPB Applic. []
Sex Title [] Mr | | | | | Relation
[] M [] F [] Mrs [] Ms [] |_|_|_|_| to PI
First/Mid | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Name |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
LAST NAME | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
& Suffix |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
[] Maiden | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
[] Known as |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Born | | | | | | | | | | | Birthplace
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 |_|_|/|_|_|
* If SCI Spouse, answer through Soc Sec only
--------------------------------------------------------------------------------
998-500
<PAGE> 4
RA018274
--------------------------------------------------------------------------------
OTHER INSURED 2
--------------------------------------------------------------------------------
Sex Title [] Mr | | | | | Relation
[] M [] F [] Mrs [] Ms [] |_|_|_|_| to PI
First/Mid | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Name |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
LAST NAME | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
& Suffix |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
[] Maiden | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
[] Known as |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Born | | | | | | | | | | | Birthplace
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 Str
(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 |_|_|/|_|_|
--------------------------------------------------------------------------------
OTHER INSURED 3
--------------------------------------------------------------------------------
Sex Title [] Mr | | | | | Relation
[] M [] F [] Mrs [] Ms [] |_|_|_|_| to PI
First/Mid | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Name |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
LAST NAME | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
& Suffix |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
[] Maiden | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
[] Known as |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Born | | | | | | | | | | | Birthplace
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 Str
(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 |_|_|/|_|_|
--------------------------------------------------------------------------------
DEPENDENT INSURED(S) UNDER SCI OR CI
(SINGLE, UNDER AGE 18, RESIDES WITH PRIMARY INSURED (PI))
--------------------------------------------------------------------------------
Full | | | | | | | | | | | | | | | | | | | | | | | | |
Name |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Relation [] M Born | | | | | | | | | | |
to PI [] F M/D/Y |_|_|/|_|_|/|_|_|_|_|
Full | | | | | | | | | | | | | | | | | | | | | | | | |
Name |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Relation [] M Born | | | | | | | | | | |
to PI [] F M/D/Y |_|_|/|_|_|/|_|_|_|_|
Full | | | | | | | | | | | | | | | | | | | | | | | | |
Name |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Relation [] M Born | | | | | | | | | | |
to PI [] F M/D/Y |_|_|/|_|_|/|_|_|_|_|
Full | | | | | | | | | | | | | | | | | | | | | | | | |
Name |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Relation [] M Born | | | | | | | | | | |
to PI [] F M/D/Y |_|_|/|_|_|/|_|_|_|_|
[] Check box if more than 4 dependents. Use Details, Q. 18.
--------------------------------------------------------------------------------
2. REFERENCES TO "YOU" OR "YOUR" IN APPLICATION QUESTIONS 2 THROUGH 18(a) MEAN:
THE "PRIMARY INSURED", "DEPENDENT INSURED(S)", OTHER INSURED(S), AS
APPLICABLE.
<TABLE>
<CAPTION>
-----------------------------------------------------------------------------------------------------------------------------------
PI OTHER 1 OTHER 2 OTHER 3
-----------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C> <C> <C> <C> <C> <C> <C>
Yes No Yes No Yes No Yes No
Do you have other Life Insurance (all Companies) in force? [] [] [] [] [] [] [] []
If "yes", Total Amount in all Companies $ $ $ $
Yes No Yes No Yes No Yes No
Do you have other Life Ins. (all Cos.) pending or issued [] [] [] [] [] [] [] []
last year?
</TABLE>
If Yes, Person Company Amount $ Plan No.
--------------------------------------------------------------------------------
998-500 2
<PAGE> 5
<TABLE>
<CAPTION>
------------------------------------------------------------------------------------------------------------------------------------
NYLIC RIDERS DIVIDEND OPTION
------------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C>
[ ] WL [ ] MPWL [ ] WP [ ] OPP [ ] COM [ ] CPB (WL only) [ ] 5YTR PI [ ] MPG [ ] IPTR [ ] 1YT (select
[ ] ADB Scheduled Bill [ ] SCI [ ] CI $ $ another option for
$ # units [ ] 5YTR/oci 1 [ ] MPG balance of Dividends)
Face Amount $ $ Unscheduled [ ] PPO $ [ ] [ ] Pd Up Ad
Premium $ [ ] DOT (Lump Sum) $ [ ] 5YTR/oci 2 [ ] MPG [ ] Accum
APL [ ] Yes $ $ [ ] SPO $ [ ] Prem
[ ] LBR $ [ ] 5YTR/oci 3 [ ] MPG [ ] Cash
[ ] UR (See Q.18(a)) $
------------------------------------------------------------------------------------------------------------------------------------
[ ] Spectra 1 Check any additional riders not automatically included in selected Spectra Life plan. [ ] 1YT (select
(includes 5YTR) [ ] WP [ ] OPP [ ] COM [ ]CPB (WL only) [ ] 5YTR PI [ ] MPG [ ] IPTR another option for
[ ] Spectra 2 [ ] ADB Scheduled Bill [ ] SCI [ ] CI $ $ balance of Dividends)
(includes 5YTR) $ # units [ ] 5YTR/oci 1 [ ] MPG [ ] Pd Up Ad
[ ] Spectra 3 $ Unscheduled [ ] PPO $ [ ] [ ] Accum
(includes DOT & [ ] DOT (Lump Sum) $ [ ] 5YTR/oci 2 [ ] MPG [ ] Prem
OPP riders)
[ ] $ $ [ ] SPO $ [ ] Cash
Face Amount $ [ ] LBR $ [ ] 5YTR/oci 3 [ ] MPG
APL [ ] Yes [ ] UR (See Q.18(a)) $
----------------------------------------------------------------------------------------------------------------------------------
[ ] SWL Modified
[ ] SWL Level 2nd to die 1st to die [ ] OPP/PUA [ ] COM (Select one)
[ ] DOT [ ] LFD Scheduled Bill [ ] Pd Up Ad
Face Amount $ $ $ $ [ ] Accum
[ ] LTR [ ] ITR Unscheduled [ ] Prem
(Lump Sum) [ ] Cash
APL [ ] Yes $ $
[ ] [ ] $
------------------------------------------------------------------------------------------------------------------------------------
[ ] 5YT [ ] WP [ ] 5YTR PI [ ] MPG [ ] 5YTR/oci 2 [ ] MPG (Select one)
[ ] ADB $ $ [ ] [ ] Accum
Face Amount $ $ [ ] 5YTR/oci 1 [ ] MPG [ ] 5YTR/oci 3 [ ] MPG [ ] Prem
[ ] LBR $ $ [ ] Cash
[ ] MPG
------------------------------------------------------------------------------------------------------------------------------------
[ ] IPT [ ] WP [ ] SCI [ ] CI (Select one)
[ ] ADB # units [ ] [ ] Accum
Face Amount $ $ [ ] PPO [ ] Prem
[ ] LBR $ [ ] Cash
Premium $
------------------------------------------------------------------------------------------------------------------------------------
[ ] [ ]
$
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
NYLAZ RIDERS
------------------------------------------------------------------------------------------------------------------------------------
[ ] Term to
Age 90 [ ] WP [ ] ADB [ ] LBR [ ]
Face Amount $ $
------------------------------------------------------------------------------------------------------------------------------------
[ ] [ ]
$
------------------------------------------------------------------------------------------------------------------------------------
</TABLE>
998-500 3
<PAGE> 6
RA081274
<TABLE>
<CAPTION>
-----------------------------------------------------------------------------------------------------------------------------------
NYLIAC RIDERS
-----------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C>
[ ] NYLIAC Accumulator [ ] MDW [ ] CI [ ] OCI 1 [ ] OCI 3 [ ]
[ ] ULGUIDE [ ] ULCVAT
[ ] NYLIAC Protector [ ] ADB # units $ $
[ ] ULGUIDE [ ] ULCVAT $ [ ] STR [ ] OCI 2
Face Amount $ [ ] GIR $ $
[ ] 1 $
OPTION {
[ ] 2
Planned $
Initial $
-----------------------------------------------------------------------------------------------------------------------------------
[ ] VUL [ ] MDW [ ] CI [ ] OCI 2 [ ] LBR [ ]
Face Amount $ [ ] ADB # units $ [ ] GMDB
[ ] 1 $ [ ] OCI PI [ ] OCI 3 to Age [ ] 70
OPTION { to Age [ ] 80
[ ] 2 [ ] GIR $ $ to Age [ ] 95
Sched. $ $ [ ] OCI 1
Initial $ $
-----------------------------------------------------------------------------------------------------------------------------------
[ ] Spectra VUL 70 [ ] Spectra VUL 80 [ ] MDW [ ] CI [ ] OCI 2 [ ] LBR [ ]
[ ] Spectra VUL 95
[ ] 1 [ ] ADB # units $
OPTION {
[ ] 2 $ [ ] OCI PI [ ] OCI 3
Face Amount $ [ ] GIR $ $
Sched. $ $ [ ] OCI 1
Initial $ $
-----------------------------------------------------------------------------------------------------------------------------------
[ ] SVUL 2nd to Die 1st to Die [ ] GMDB [ ]
Face Amount $ [ ] STR [ ] FTD to Age [ ] 80
[ ] 1 $ $ to Age [ ] 100
OPTION {
[ ] 2 [ ] FTD-MDW
Planned $
Initial $
-----------------------------------------------------------------------------------------------------------------------------------
[ ] Asset Preserver (UL/LTC) Submit completed Asset Preserver Application Supplement
Face Amount $
Premium $
Option: [ ] LTC 24
[ ] LTC 36+
[ ] LTC 48+
-----------------------------------------------------------------------------------------------------------------------------------
[ ] SPL
Face Amount $ [ ] LBR [ ]
Premium $
-----------------------------------------------------------------------------------------------------------------------------------
[ ]
$ [ ]
-----------------------------------------------------------------------------------------------------------------------------------
3. ENDORSEMENTS AND OTHER REQUESTS
-----------------------------------------------------------------------------------------------------------------------------------
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
-----------------------------------------------------------------------------------------------------------------------------------
4. MODE [ ] Ann [ ] Semi [ ] Qrtly [ ] COM [ ] Nyla [ ] Gvt [ ] Arr. for U.S. Tax Qual. Plan [ ] (All modes not available
on all plan
-----------------------------------------------------------------------------------------------------------------------------------
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
M/D/Y |_|_| / |_|_| / |_|_|_|_|
(b) the policy's date of issue, if cash not paid; or DATE
-----------------------------------------------------------------------------------------------------------------------------------
</TABLE>
998-500
4
<PAGE> 7
<TABLE>
<S> <C>
------------------------------------------------------------------------------------------------------------------------------------
6. REPLACEMENT
------------------------------------------------------------------------------------------------------------------------------------
(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".
------------------------------------------------------------------------------------------------------------------------------------
7. BENEFICIARY (SUBJECT TO CHANGE) COMPLETE SECTION A OR B. MUST COMPLETE SECTION B FOR NON-STANDARD BENEFICIARY OR OCI AND 5YTR
BENEFICIARY.
------------------------------------------------------------------------------------------------------------------------------------
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
[ ] CI Standard Family Designation [ ] Trust
[ ] CI Special Standard Family Designation Name of Trustee
Spouse Name of Trust
[ ] SCI Standard Family Designation
Date of Trust
Spouse
[ ] Uniform Transfers to Minors
as custodian for under the Uniform Transfers/Gifts Minors Act (UTMA)
(Minor) (State)
------------------------------------------------------------------------------------------------------------------------------------
B.[ ] Named Beneficiaries (indicate Order as 1st, 2nd, etc.)
Insured(s) Name Order Beneficiary Name Relationship to Insured
------------------------------------------------------------------------------------------------------------------------------------
8. CURRENT HEALTH PI DEPS. OTHER 1 OTHER 2 OTHER 3
------------------------------------------------------------------------------------------------------------------------------------
Note: "No" may only be checked for dependents if it applies to all dependents named in Q. 1.
(a) In the last 2 years: have you been unable to work or unable Yes No Yes No Yes No Yes No 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 Yes No Yes No Yes No Yes No Yes No
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 for that person in all
cases.
------------------------------------------------------------------------------------------------------------------------------------
</TABLE>
998-500 5
<PAGE> 8
RA081274
<TABLE>
<S> <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 terms of
the attached receipt, that any coverage will be provided only as stated in the attached receipt and only if all Yes No
conditions to coverage are met, and that any such coverage will be temporary and limited in amount? [ ] [ ]
If "No" to 9(a), or if either part of Questions 8(a) or 8(b) is answered "Yes", cash cannot be paid.
(b) TOTAL CASH PAID? $ If amendment, cash previously paid: $
------------------------------------------------------------------------------------------------------------------------------------
10. Is a spouse or dependent child applying for SCI/CI Ins. coverage? (If yes, see Page 2) Yes [ ] No [ ]
------------------------------------------------------------------------------------------------------------------------------------
11. INSURANCE ON CHILD Answer if Proposed or Other Covered Insured under 14 yrs. 6 mos. (explain any "No" in Details.)
------------------------------------------------------------------------------------------------------------------------------------
Yes No
(a) Is Applicant a parent or legal guardian (attach proof of guardianship) of Proposed Insured or Other Covered
Insured? ......................................................................................................... [ ] [ ]
(b) Is Applicant employed and providing Proposed Insured's or Other Covered Insured's main support? .................. [ ] [ ]
(c) Is all life insurance in force on Applicant at least equal to that on Proposed Insured or Other 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 or
Other Insured? ................................................................................................... [ ] [ ]
------------------------------------------------------------------------------------------------------------------------------------
12. TOBACCO/NICOTINE PI OTHER 1 OTHER 2 OTHER 3
------------------------------------------------------------------------------------------------------------------------------------
If age 18 or over on Policy Date, have you used tobacco or
nicotine in any form, in the last 5 years? YES NO YES NO YES NO YES NO
[ ] [ ] [ ]* [ ]* [ ] [ ] [ ] [ ]
If "Yes", indicate type used
date of last use / / / /
MO YR MO YR MO YR MO YR
*NOT REQUIRED
IF SCI SPOUSE
------------------------------------------------------------------------------------------------------------------------------------
13. UNDERWRITING DATA PI DEPENDENTS OTHER 1 OTHER 2 OTHER 3
------------------------------------------------------------------------------------------------------------------------------------
Note: "No" may only be checked for dependents if it applies to all dependents named in Q.1. If "Yes", submit Form 7663
(a) In last 2 years, have you engaged in or do you
now intend to engage in?
aircraft flying, other than as a passenger [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO
motorcycle driving [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO
snowmobile driving [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO
motorized racing [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO
scuba diving [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO
ballooning [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO
parachuting [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO
hang gliding [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO
ultralight flying [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO
mountaineering [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO
rodeo riding [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO [ ]YES [ ]NO
Each part of this Q. is answered: [ ]NO [ ]NO [ ]NO [ ]NO [ ]NO
------------------------------------------------------------------------------------------------------------------------------------
(b) Do you have a current driver's license? YES NO YES NO YES NO YES NO YES NO
[ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]
------------------------------------------------------------------------------------------------------------------------------------
(c) In the last 5 years, have you had your driver's
license suspended or revoked? If yes, give YES NO YES NO YES NO YES NO YES NO
details, dates, driver's license # and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]
State of license in Details, Q.18.
------------------------------------------------------------------------------------------------------------------------------------
(d) In last 5 years, have you been arrested,
convicted or imprisoned for any reason? YES NO YES NO YES NO YES NO YES NO
If yes, give details in Q.18. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]
------------------------------------------------------------------------------------------------------------------------------------
(e) Are you a citizen of the United States? YES NO YES NO YES NO YES NO YES NO
If no, give country of citizenship in Q.18. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]
------------------------------------------------------------------------------------------------------------------------------------
(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 mos?
If yes, give Where, When, How long in Details, YES NO YES NO YES NO YES NO YES NO
Q.18. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]
------------------------------------------------------------------------------------------------------------------------------------
(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 YES NO YES NO YES NO YES NO
Company name and reason in Details, Q.18. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]
------------------------------------------------------------------------------------------------------------------------------------
</TABLE>
998-500 6
<PAGE> 9
Details are required for all "Yes" answers to Q. 14-17. Do not answer Q. 14-17
if Part II is required.
<TABLE>
<CAPTION>
----------------------------------------------------------------------------------------------------------------------------------
14. MEDICAL UNDERWRITING PI DEPENDENTS OTHER 1 OTHER 2 OTHER 3
----------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C> <C> <C> <C>
(a) In last 10 years have you
had or been treated for:
heart disorder [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
angina [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
stroke [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
irregular pulse [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
hypertension [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
diabetes [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
cancer [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
tumor [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
Each part of this Q. is answered: [ ] No [ ] No [ ] No [ ] No [ ] No
----------------------------------------------------------------------------------------------------------------------------------
(b) In last 10 years have you
been counseled, treated, or
hospitalized for:
psychiatric condition [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
emotional condition [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
mental health condition [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
Each part of this Q. is answered: [ ] No [ ] No [ ] No [ ] No [ ] No
----------------------------------------------------------------------------------------------------------------------------------
(c) In last 10 years have you used
cocaine [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
other controlled substance [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
or have you been counseled,
treated or hospitalized for
drug use [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
Each part of this Q. is answered: [ ] No [ ] No [ ] No [ ] No [ ] No
----------------------------------------------------------------------------------------------------------------------------------
(d) In last 10 years have you been
absent from work because of
alcohol use [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
or have you been counseled,
treated or hospitalized for
alcohol use [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
Each part of this Q. is answered: [ ] No [ ] No [ ] No [ ] No [ ] No
----------------------------------------------------------------------------------------------------------------------------------
15. In last 2 years have you had or
been treated for:
(a) unexplained weight loss [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
swollen glands [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
recurring diarrhea [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
recurring fever [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
recurring infection [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
persistent cough [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
pneumonia [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
thrush [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
Each part of this Q. is answered: [ ] No [ ] No [ ] No [ ] No [ ] No
----------------------------------------------------------------------------------------------------------------------------------
(b) edema [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
transient visual loss [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
muscle weakness [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
back or spine disorder [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
shortness of breath [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
internal bleeding [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
Each part of this Q. is answered: [ ] No [ ] No [ ] No [ ] No [ ] No
----------------------------------------------------------------------------------------------------------------------------------
16. In last 5 years have you had
or been treated for:
(a) chronic respiratory disorder [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
kidney disorder [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
intestinal disorder [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
blood disorder [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
circulatory disorder [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
seizures [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
other nervous system disorder [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
Each part of this Q. is answered: [ ] No [ ] No [ ] No [ ] No [ ] No
----------------------------------------------------------------------------------------------------------------------------------
(b) liver disorder [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
pancreas disorder [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
immune system disorder
(including AIDS or AIDS-
Related Complex) [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
Each part of this Q. is answered: [ ] No [ ] No [ ] No [ ] No [ ] No
----------------------------------------------------------------------------------------------------------------------------------
*
17. Your height (ft., in.)
Your weight (lbs.)
----------------------------------------------------------------------------------------------------------------------------------
* Not required if SCI Spouse
</TABLE>
998-500 7
<PAGE> 10
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 Q. No. if applicable).
<TABLE>
<CAPTION>
# Name Details Name, Addr of Dr./Hosp.
------------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C> <C>
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
====================================================================================================================================
8(a) Answer for UR rider only:
2 PI 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
Name |_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_|
LAST NAME
& Suffix |_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_|
Born
M/D/Y |_||_|/|_||_|/|_||_||_||_|
Soc Tax
Sec |_||_||_|-|_||_|-|_||_||_||_| ID# |_||_|-|_||_||_||_||_||_||_|
Relationship to Proposed Insured
[ ] Spouse [ ] Parent [ ] Employer [ ] UTMA [ ]
Address [ ] Same as PI Res [ ] Same as PI Bus [ ] other as follows
Address
City
State |_||_|Zip |_||_||_||_||_| + |_||_||_||_|
Employer
Business
Street
City
Mail
State |_||_|Zip |_||_||_||_||_| + |_||_||_||_|Address [ ]Res [ ]Bus
=======================================================================
20. OWNER (IF NOT PROPOSED INSURED)
-----------------------------------------------------------------------------
First/Mid
Name |_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_|
LAST NAME
& Suffix |_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_|
Born
M/D/Y |_||_|/|_||_|/|_||_||_||_|
Soc Tax
Sec |_||_||_|-|_||_|-|_||_||_||_| ID# |_||_|-|_||_||_||_||_||_||_|
Relationship to Proposed Insured
[ ] Spouse [ ] Parent [ ] Employer [ ] UTMA [ ]
Are you a citizen of the United States? [ ] Yes [ ] No
If no, give country of citizenship
Address
City
State |_||_|Zip |_||_||_||_||_| + |_||_||_||_|
If Corp., Date. |_||_||_||_||_||_|
Where Inc. Inc. MO DAY YR
Successor Owner Relationship
[ ] PI [ ] as below to Prop Insd
Name |_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_||_|
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, has any person proposed
for coverage: 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. [ ] [ ]
====================================================================================================================================
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
------------------------------------------------------------------------------------------------------------------------------------
</TABLE>
500-998 8
<PAGE> 11
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 Q. No. if applicable).
<TABLE>
<CAPTION>
<S> <C> <C> <C>
Q.# Name Details Name, Addr. of Dr./Hosp.
----------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
==================================================================================================================================
18(a) Answer for UR rider only:
2 PI 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|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| Address
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|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| Address
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, has any person YES NO
proposed for coverage:
(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.
==================================================================================================================================
22. EXERCISING A GUARANTEED INSURABILITY OPTION
----------------------------------------------------------------------------------------------------------------------------------
(a) Option Date (b) [ ] Scheduled Option Date [ ] Alternate Option Date
(b) If Alternate Option Date [ ] date of marriage [ ] birth [ ] adoption Mo. Day Year Submit proof of event
----------------------------------------------------------------------------------------------------------------------------------
</TABLE>
98-500 8
<PAGE> 12
===============================================================================
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.
<TABLE>
<CAPTION>
Age Basis Convert All: Convert Partial:
<S> <C> <C>
[ ] 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
[ ] SCI/CI/FI
</TABLE>
<TABLE>
<S> <C>
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
</TABLE>
Is Additional coverage being applied for? [ ] Yes [ ] No If "Yes", refer to
General Requirements for Various Types of Requested Actions
-------------------------------------------------------------------------------
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 all persons to
be covered are 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 those persons, 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 M/D/Y / / Signature of 1st Other Insured Signature of Applicant
I certify I have truly and accurately recorded
all answers given to me. Signature of 2nd Other Insured Signature of Proposed Insured if
other than Applicant
Witness
Agent
Signature of 3rd Other Insured Signature of Owner, if other than
Applicant or Proposed Insured
Print Agent's Name
Signature of Parent if Proposed Insured is
Agent's License No. (if reqd. by law) under 14 yrs 6 mos and Parent has not
signed as Applicant Title if signed on behalf of
corporation, trust, etc:
Countersigned by Lic. resident agt.(if reqd.)
Countersign Code# Surname Other Required Signature
</TABLE>
The signatures above apply to the application and the certification of
Taxpayer Identification Number
-------------------------------------------------------------------------------
998-500 9
