NEW YORK LIFE INS & ANNUITY CORP VAR UNIV LIFE SEP ACC I
S-6, EX-99.5, 2000-10-11
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<PAGE>   1
                                                                       EXHIBIT 5

        INSURED -- JOHN DOE
        POLICY NUMBER -- 66 000 000
        POLICY DATE -- FEBRUARY 1, 2001



NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION
(A Delaware Corporation)

THE CORPORATION will pay the benefits of this policy in accordance with its
provisions. The pages that follow are also a part of this policy.

RIGHT TO EXAMINE POLICY. Please examine your policy. Within 20 days after
delivery, you can return the policy to the Corporation or to the Registered
Representative through whom it was purchased. If this policy is returned, the
policy will be void from the start and a refund will be made. The amount we
refund will equal the greater of the policy's cash value as of the date the
policy is returned or the premiums paid, less loans and withdrawals.

VARIABLE LIFE INSURANCE BENEFIT. THE LIFE INSURANCE BENEFIT OF THIS POLICY MAY
INCREASE OR DECREASE, DEPENDING ON THE INVESTMENT EXPERIENCE OF THE SEPARATE
ACCOUNT. FURTHER INFORMATION REGARDING THIS BENEFIT IS GIVEN IN THE LIFE
INSURANCE BENEFITS SECTION ON PAGE 4 OF THE POLICY.

CASH VALUE. TO THE EXTENT THE POLICY'S CASH VALUE IS ALLOCATED TO THE INVESTMENT
DIVISIONS OF THE SEPARATE ACCOUNT, THE CASH VALUE OF THIS POLICY WILL VARY FROM
DAY TO DAY REFLECTING THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT. THE
METHOD OF DETERMINING THE CASH VALUE IS DESCRIBED IN THE CASH VALUE AND LOANS
SECTION. THERE IS NO GUARANTEED MINIMUM CASH VALUE.

EFFECTIVE DATE OF COVERAGE. Coverage under this policy will take effect on the
later of the policy date or the date we receive your initial premium payment.


                                          /s/ FREDERICK J. SIEVERT
                                          President

                                          /s/ GEORGE J. TRAPP
                                          Secretary



MODIFIED SINGLE PREMIUM VARIABLE UNIVERSAL LIFE INSURANCE POLICY

Variable Life Insurance Benefit - Modified Single Premium Payments Proceeds
Payable at Insured's Death.
AMOUNT OF VARIABLE LIFE INSURANCE OR CASH VALUE PROCEEDS MAY VARY, REFLECTING
INVESTMENT EXPERIENCE OF SEPARATE ACCOUNT.
Limited Premium Flexibility - No Premiums Payable on or After Age 100.
Policy is Non-Participating.

301-95


<PAGE>   2



INSURED --  JOHN DOE                            INSURED'S AGE AND SEX
                                                AT ISSUE - 35 MALE
POLICY NUMBER --  66 000 000

                                                INSURED'S CLASS
     POLICY DATE  --  FEBRUARY 1, 2001          OF RISK  --  PREFERRED
     ISSUE DATE  --   FEBRUARY 1, 2001

            PLAN  --  NYLIAC SINGLE PREMIUM VARIABLE UNIVERSAL LIFE

INITIAL FACE AMOUNT -- $100,000
DEATH BENEFIT GUARANTEE AMOUNT -- $100,000


BENEFICIARY/OWNER AS DESIGNATED IN THE APPLICATION UNLESS CHANGED AS PROVIDED IN
THE POLICY.



INITIAL SINGLE PREMIUM: $17,221.39*
GUIDELINE SINGLE PREMIUM: $17,221.39
GUIDELINE ANNUAL PREMIUM: $1,339.19
GUIDELINE SINGLE PAYMENT PERCENTAGE: 100%



*  ADDITIONAL UNPLANNED PREMIUMS CANNOT BE PAID ON OR AFTER THE POLICY
   ANNIVERSARY ON WHICH THE INSURED IS AGE 100, WHICH IS FEBRUARY 1, 2066. IF A
   DEATH BENEFIT GUARANTEE IS NOT IN EFFECT, COVERAGE WILL EXPIRE WHEN THE CASH
   VALUE LESS SURRENDER CHARGES AND ANY UNPAID LOAN AND ACCRUED INTEREST IS
   INSUFFICIENT TO COVER THE MONTHLY DEDUCTION. IN ADDITION, BECAUSE POLICY
   VALUES ARE BASED ON THE INVESTMENT PERFORMANCE OF THE SEPARATE ACCOUNT,
   PAYMENT OF UNPLANNED PREMIUMS IN ANY FREQUENCY OR AMOUNT MAY NOT GUARANTEE
   THAT THE POLICY WILL REMAIN IN FORCE UNTIL THE MATURITY DATE. HOWEVER, IF AN
   AMOUNT OTHER THAN ZERO IS SHOWN AS THE DEATH BENEFIT GUARANTEE AMOUNT ABOVE,
   COVERAGE IS GUARANTEED NOT TO EXPIRE AS LONG AS THE DEATH BENEFIT GUARANTEE
   IS IN EFFECT.


MONTHLY DEDUCTION DAY - FIRST DAY OF EACH CALENDAR MONTH







PAGE 2    POLICY DATA   NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION
0195-2



<PAGE>   3



POLICY NUMBER --  66 000 000                    INSURED -  JOHN DOE






THE FIXED ACCOUNT WILL BE CREDITED WITH INTEREST AT A RATE THAT WE SET IN
ADVANCE AT LEAST ANNUALLY. THIS RATE IS GUARANTEED TO BE AT LEAST 3% PER YEAR.


THE MORTALITY TABLE REFERRED TO IN SECTION 8.18 IS THE COMMISSIONERS' 1980
STANDARD ORDINARY SMOKER OR NONSMOKER TABLE OF MORTALITY.

















PAGE 2 (Cont)    POLICY DATA     NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION
0195-2



<PAGE>   4



POLICY NUMBER --  66 000 000                    INSURED -  JOHN DOE


                              TABLE OF EXPENSE CHARGES

MONTHLY CHARGES WHICH ARE DEDUCTED:

-  MONTHLY COST OF INSURANCE FOR THE BASIC POLICY.

-  A MONTHLY ADMINISTRATIVE CHARGE THAT WILL NOT EXCEED, ON AN ANNUAL
   BASIS, .70% OF THE AMOUNT OF CASH VALUE YOU HAVE IN THE SEPARATE AND FIXED
   ACCOUNTS (INCLUDING ANY LOANED AMOUNTS) AFTER THE COST OF INSURANCE HAS BEEN
   DEDUCTED.

-  A DEFERRED SALES EXPENSE CHARGE THAT WILL NOT EXCEED, ON AN ANNUAL BASIS,
   1.00% OF THE AMOUNT OF CASH VALUE YOU HAVE IN THE SEPARATE AND FIXED
   ACCOUNTS, INCLUDING ANY LOANED AMOUNTS, AND AFTER THE COST OF INSURANCE HAS
   BEEN DEDUCTED, FOR 10 YEARS AFTER ANY PREMIUM PAYMENT. THE DEFERRED SALES
   EXPENSE CHARGE INCLUDES (1) A STATE TAX CHARGE, ON AN ANNUAL BASIS, OF .30%
   AND (2) A FEDERAL TAX (DAC) CHARGE, ON AN ANNUAL BASIS, OF .20%. WE RESERVE
   THE RIGHT TO CHANGE THESE PERCENTAGES TO CONFORM TO CHANGES IN THE LAW.

OTHER CHARGES AGAINST THE POLICY:

-  PARTIAL WITHDRAWALS ARE SUBJECT TO A PROCESSING CHARGE EQUAL TO THE LESSER OF
   $25.00 OR 2% OF THE AMOUNT THAT IS BEING WITHDRAWN. THE MINIMUM AMOUNT THAT
   CAN BE WITHDRAWN IS $500.00.

-  WE RESERVE THE RIGHT TO APPLY A CHARGE, NOT TO EXCEED $30, FOR EACH TRANSFER
   OF FUNDS AFTER THE FIRST TWELVE IN A GIVEN POLICY YEAR BETWEEN INVESTMENT
   DIVISIONS AND/OR THE FIXED ACCOUNT.

-  WE RESERVE THE RIGHT TO MAKE A CHARGE FOR SEPARATE ACCOUNT FEDERAL INCOME TAX
   LIABILITIES IF THE LAW SHOULD CHANGE TO REQUIRE TAXATION OF SEPARATE
   ACCOUNTS.


CHARGE AGAINST THE SEPARATE ACCOUNT:

-  THE FACTOR WHICH REPRESENTS THE MORTALITY AND EXPENSE RISK CHARGE REFERRED TO
   IN THE SEPARATE ACCOUNT SECTION OF THIS POLICY WILL NOT EXCEED, ON AN ANNUAL
   BASIS, .80% OF THE NET ASSET VALUE OF A FUND SHARE HELD IN THE SEPARATE
   ACCOUNT FOR EACH INVESTMENT DIVISION. THIS CHARGE IS DEDUCTED DAILY.














PAGE 2.1     POLICY DATA         NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION
0195-2.1


<PAGE>   5




POLICY NUMBER --  66 000 000                    INSURED -  JOHN DOE


INITIAL SINGLE PREMIUM:  $17,221.39


                       TABLE OF MAXIMUM SURRENDER CHARGES

<TABLE>
<CAPTION>
POLICY            PERCENTAGE        MAXIMUM
YEAR              APPLIED           SURRENDER CHARGE

<S>                 <C>             <C>
  1                 9%              $1,549.89
  2                 8%              $1,377.68
  3                 7%              $1,205.47
  4                 6%              $1,033.26
  5                 5%              $  861.05
  6                 4%              $  688.84
  7                 3%              $  516.63
  8                 2%              $  344.42
  9                 1%              $  172.21
10 & LATER          0%              $       0
</TABLE>


THE MAXIMUM SURRENDER CHARGE IS CALCULATED BY MULTIPLYING THE INITIAL SINGLE
PREMIUM BY THE APPLICABLE PERCENTAGE SHOWN IN THE TABLE ABOVE.

A SURRENDER CHARGE, CALCULATED AS AN ANNUALLY DECREASING PERCENTAGE (SHOWN
ABOVE) OF THE CASH VALUE AND SUBJECT TO THE MAXIMUM CHARGE ALSO SHOWN ABOVE,
WILL BE APPLIED TO A FULL SURRENDER MADE UNDER THIS POLICY IN THE FIRST 9 YEARS.
THIS SURRENDER CHARGE WILL NOT BE APPLIED TO ANY AMOUNT PERMITTED TO BE
WITHDRAWN FROM THE POLICY WITHOUT INCURRING A SURRENDER CHARGE, AS DESCRIBED IN
SECTION 6.3.

A SURRENDER CHARGE MAY BE APPLIED TO ANY PARTIAL WITHDRAWAL TAKEN UNDER THIS
POLICY, AS DESCRIBED IN SECTION 6.3 OF THIS POLICY.










PAGE 2.2     POLICY DATA         NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION
0195-2.2


<PAGE>   6




                 TABLE OF PERCENTAGES FOR LIFE INSURANCE BENEFIT
                      FOR COMPLIANCE WITH IRC SECTION 7702
                             GUIDELINE PREMIUM TEST




<TABLE>
<CAPTION>
   INSURED'S AGE        PERCENT           INSURED'S AGE     PERCENT
   ON POLICY            OF CASH           ON POLICY         OF CASH
   ANNIVERSARY          VALUE             ANNIVERSARY       VALUE
   -----------          -----             -----------       -----
<S>                     <C>                   <C>             <C>
    0-40                250                   68              117
      41                243                   69              116
      42                236                   70              115
      43                229                   71              113
      44                222                   72              111
      45                215                   73              109
      46                209                   74              107
      47                203                   75              105
      48                197                   76              105
      49                191                   77              105
      50                185                   78              105
      51                178                   79              105
      52                171                   80              105
      53                164                   81              105
      54                157                   82              105
      55                150                   83              105
      56                146                   84              105
      57                142                   85              105
      58                138                   86              105
      59                134                   87              105
      60                130                   88              105
      61                128                   89              105
      62                126                   90              105
      63                124                   91              104
      64                122                   92              103
      65                120                   93              102
      66                119                   94              101
      67                118                   95-100          100
</TABLE>












PAGE 2.3   POLICY DATA  NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION
0195-2.3


<PAGE>   7




         TABLE OF GUARANTEED MAXIMUM MONTHLY COST OF INSURANCE RATES
                           (PER $1,000 OF FACE AMOUNT)

                                      MALE

 THE RATES SHOWN BELOW ARE BASED ON THE 1980 CSO NONSMOKER TABLE OF MORTALITY


<TABLE>
<CAPTION>
               AGE                           AGE
<S>            <C>            <C>            <C>            <C>
               18             .13            59               .96
               19             .14            60              1.05
               20             .14            61              1.16
               21             .14            62              1.29
               22             .14            63              1.43
               23             .13            64              1.59
               24             .13            65              1.76
               25             .13            66              1.95
               26             .12            67              2.16
               27             .12            68              2.38
               28             .12            69              2.62
               29             .12            70              2.89
               30             .12            71              3.25
               31             .12            72              3.56
               32             .13            73              3.97
               33             .13            74              4.43
               34             .13            75              4.92
               35             .14            76              5.45
               36             .15            77              6.01
               37             .16            78              6.58
               38             .17            79              7.20
               39             .18            80              7.87
               40             .19            81              8.62
               41             .21            82              9.47
               42             .22            83             10.42
               43             .24            84             11.47
               44             .26            85             12.59
               45             .28            86             13.75
               46             .30            87             14.95
               47             .32            88             16.17
               48             .35            89             17.41
               49             .38            90             18.69
               50             .41            91             20.05
               51             .45            92             21.52
               52             .49            93             23.16
               53             .54            94             25.26
               54             .59            95             28.27
               55             .65            96             33.11
               56             .72            97             41.69
               57             .79            98             58.01
               58             .87            99             83.33
</TABLE>






PAGE 2A     POLICY DATA        NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION
0195-2A


<PAGE>   8


      WE & YOU
      In this policy, the words "we",              When you write to us,
      "our" and "us" refer to New York             please include the policy
      Life Insurance and Annuity                   number, the Insured's full
      Corporation, and the words                   name, and your current
      "you" and "your" refer to the                address.
      Owner of this policy.

----------------------------------  CONTENTS  ----------------------------------


<TABLE>
<CAPTION>
      SECTION           PROVISIONS                             PAGE
      -------           ----------                             ----
<S>                     <C>                                    <C>
                        POLICY DATA PAGES

      ONE               LIFE INSURANCE BENEFITS                4

      TWO               OWNER AND BENEFICIARY                  5

      THREE             PREMIUMS                               6-7

      FOUR              SEPARATE ACCOUNT                       8-10

      FIVE              FIXED ACCOUNT                          10

      SIX               CASH VALUE AND LOANS                   11-14

      SEVEN             PAYMENT OF POLICY PROCEEDS             14-16

      EIGHT             GENERAL PROVISIONS                     16-18

                        APPLICATION - Attached to the Policy

                        RIDERS OR ENDORSEMENTS
                        (IF ANY) - Attached to the Policy
</TABLE>




READ YOUR POLICY CAREFULLY.  THIS POLICY IS A LEGAL CONTRACT BETWEEN YOU AND
US.

















                                     PAGE 3
                                     0195-3

<PAGE>   9



                      SECTION ONE - LIFE INSURANCE BENEFITS


1.1 IS A LIFE INSURANCE BENEFIT PAYABLE UNDER THIS POLICY? We will pay the life
    insurance proceeds to the beneficiary promptly, when we have proof that the
    Insured died while the life insurance under this policy was in effect. The
    proceeds payable under this policy consist of the life insurance benefit of
    the policy, less any unpaid loan and accrued interest and any past due
    Monthly Deductions.


1.2 WHAT IS THE LIFE INSURANCE BENEFIT UNDER THIS POLICY? This policy provides a
    life insurance benefit equal to the greater of the face amount of the
    policy, which reflects any changes made in accordance with the provisions of
    this policy, or a percentage of the cash value equal to the minimum
    necessary for this policy to qualify as life insurance under Section 7702 of
    the Internal Revenue Code, as amended. (See Policy Data page 2.3 for a table
    of these percentages.)


1.3 WHEN IS A LIFE INSURANCE BENEFIT GUARANTEED TO BE PAID UNDER THIS POLICY? If
    the initial single premium amount paid is based on 100% of the Guideline
    Single Premium for the Initial Face Amount shown on the policy data page, a
    Death Benefit Guarantee is in effect for the policy. At issue, the life
    insurance benefit is equal to the Death Benefit Guarantee Amount.


1.4 CAN THE DEATH BENEFIT GUARANTEE CHANGE? Yes. If a loan and/or interest due
    cause the total loan principal to exceed 50% of the cash value at any time,
    the Death Benefit Guarantee will terminate. The Death Benefit Guarantee
    Amount can also change when a partial withdrawal is taken (as described in
    Section 6.6) or when the Insured reaches age 100 (as described in Section
    1.6).


1.5 CAN A DEATH BENEFIT GUARANTEE BE REINSTATED?  No.  Once terminated, the
    Death Benefit Guarantee can not be reinstated.


1.6 DOES THE DEATH BENEFIT GUARANTEE END WHEN THE INSURED REACHES AGE 100? This
    policy matures on the policy anniversary on which the Insured is age 100 (as
    defined in Section 8.6). When this happens, the Death Benefit Guarantee
    Amount will be the greater of the Death Benefit Guarantee Amount at maturity
    or the cash value. On that policy anniversary when the Insured is age 100,
    the cash value will be moved into a cash management account and all policy
    charges will end. However, if there is an outstanding loan, loan interest
    will continue to be charged beyond age 100. The designated beneficiary will
    be paid the Death Benefit Guarantee Amount, less any outstanding loan and
    accrued interest, at the Insured's death.

    If you prefer, you can advise us prior to the date the policy matures, that
    you want to remain invested in the separate accounts and not have the Death
    Benefit Guarantee continue as described above. Or, you can choose to
    surrender the policy for its cash surrender value.


1.7 WHAT HAPPENS WHEN THE INSURED REACHES AGE 100 AND THERE IS NO DEATH BENEFIT
    GUARANTEE IN EFFECT? Beginning on the anniversary on which the Insured is
    age 100 (as defined in Section 8.6), the face amount of this policy shown on
    the Policy Data page will no longer apply. Instead, the life insurance
    benefit of this policy will equal the cash value as defined in Section 6.1.
    No further monthly deductions will be made from this cash value. You can
    surrender the policy for the cash surrender value proceeds by submitting to
    us a signed written request that gives us the facts that we need. If this
    policy is still in force upon the death of the Insured, the life insurance
    benefit will be paid to the beneficiary. We will deduct any unpaid loan and
    accrued interest.



                                     PAGE 4
                                     0195-4


<PAGE>   10



                       SECTION TWO - OWNER AND BENEFICIARY


2.1 WHO IS THE OWNER OF THIS POLICY? The owner of this policy is shown on the
    Policy Data page. In this policy, the words "you" and "your" refer to the
    policyowner.


2.2 CAN A SUCCESSOR TO THE OWNER BE NAMED? Yes, a successor owner can be named
    in the application, or in a notice you sign which gives us the facts that we
    need. If you die before the successor owner, the successor owner will become
    the new owner. If no successor owner survives you and you die before the
    Insured, your estate becomes the new owner.


2.3 HOW IS THE OWNER OF THIS POLICY CHANGED? You can change the owner of this
    policy, in a notice you sign which gives us the facts that we need. This
    change will take effect as of the date you sign the notice, subject to any
    payment we made or action we took before recording this change. When this
    change takes effect, all rights of ownership pass to the new owner. Changing
    the owner does not change the beneficiary.


2.4 CAN A BENEFICIARY BE CHANGED? While the Insured is living, you can change a
    beneficiary in a notice you sign which gives us the facts that we need. This
    change will take effect as of the date you signed the notice, subject to any
    payment we made or action we took before recording the change.


2.5 CAN MORE THAN ONE BENEFICIARY BE NAMED FOR THIS POLICY? Yes, one or more
    beneficiaries for any life insurance proceeds can be named in the
    application. If more than one beneficiary is named, they can be classed as
    first, second and so on. If 2 or more are named in a class, their shares in
    the proceeds are equal, unless you state otherwise. The stated shares of the
    proceeds will be paid to any first beneficiaries who survive the Insured. If
    no first beneficiaries survive, payment will be made to any beneficiaries
    surviving in the second class, and so on.


2.6 WHAT HAPPENS IF NO BENEFICIARY IS LIVING WHEN THE PROCEEDS BECOME PAYABLE?
    If no beneficiary for the life insurance proceeds, or for a stated share,
    survives the Insured, the right to these proceeds, or this share, will pass
    to you. If you are the Insured, this right will pass to your estate.


2.7 WHAT IF THE BENEFICIARY AND THE INSURED DIE AT THE SAME TIME? Unless stated
    otherwise in the policy or in your signed notice which is in effect at the
    Insured's death, if any beneficiary dies at the same time as the Insured, or
    within 15 days after the Insured but before we receive proof of the
    Insured's death, we will pay the proceeds as though that beneficiary died
    first.












                                     PAGE 5
                                     0195-5


<PAGE>   11

                            SECTION THREE - PREMIUMS


3.1 ARE THERE ANY LIMITATIONS TO THE AMOUNT OF PREMIUMS THAT CAN BE PAID? Your
    Initial Single Premium must be based on either 100% of the Guideline Single
    Premium or 80% of the Guideline Single Premium for the amount of insurance
    you have selected and at the rate class your policy is issued. The Initial
    Single Premium and its applicable Guideline Single Payment Percentage are
    shown on the Policy Data Page. Premiums can not be paid if such payments
    would cause the policy to no longer qualify as Life Insurance, as defined
    under the guideline premium test requirements of Section 7702 of the
    Internal Revenue Code of 1986, as amended. If the premium paid during any
    policy year exceeds the maximum permitted under the Internal Revenue Code,
    we will return any such excess within 60 days after the end of the policy
    year in which the payment was made, with interest at a rate never less than
    3% annually.


3.2 WHAT ARE UNPLANNED PREMIUMS? Unplanned premiums are payments you can make in
    addition to the Initial Single Premium.


3.3 WHAT UNPLANNED PREMIUM WILL BE ALLOWED? Provided the Insured is living and
    payment is made prior to the policy anniversary on which the Insured is age
    100, unplanned premium payments can be paid within Guideline Limits as
    specified under Section 7702 of the Internal Revenue Code of 1986, as
    amended. The unplanned premium can not exceed the greater of: (a) the
    Guideline Single Premium, less the sum of all prior premiums paid or (b) the
    sum of the Guideline Annual Premiums to the date of payment less the sum of
    all prior premiums paid. If the Initial Single Premium paid at issue is 80%
    of the Guideline Single Premium, then unplanned premiums may be paid up to
    an amount that equals the Guideline Single Premium (less the sum of prior
    premiums paid.) Partial withdrawals may affect the premiums that can be
    paid. If an unplanned premium payment would result in an increase in the
    life insurance benefit greater than the increase in the cash value, we
    reserve the right to require proof of insurability before accepting that
    payment (which is subject to a $500 minimum unless we agree otherwise) and
    applying it to the policy.

    An additional premium can be paid at our Home Office or at any other
    location that we indicate to you in writing. Our acceptance of any unplanned
    premium payments under this option will not purchase a Death Benefit
    Guarantee. Any unplanned premiums that we receive will first be applied to
    reduce an outstanding loan and any interest due.


3.4 HOW ARE YOUR PREMIUM PAYMENTS ALLOCATED? After the expiration of the
    policy's Examination Period described on the front cover, your initial
    premium payment is applied to the Separate Account and/or Fixed Account in
    accordance with your premium allocation election and before any other
    deductions due are made. Any unplanned premium payments not used to repay a
    loan or loan interest will be allocated to the Separate Account or Fixed
    Account in accordance with your premium allocation in effect at the time we
    receive your payment.


3.5 CAN YOUR PREMIUM ALLOCATION ELECTION BE CHANGED? Yes, you can change your
    premium allocation election stated in the application by submitting a signed
    written request. Your allocation percentages must total 100%. Each
    percentage must be either zero, or a whole number which is at least 1%. This
    change will take effect on the date we receive the signed request.




                                     PAGE 6
                                     0195-6


<PAGE>   12



                      SECTION THREE - PREMIUMS (CONTINUED)


3.6  WHAT HAPPENS IF THE POLICY VALUE IS NOT SUFFICIENT TO COVER POLICY CHARGES?
     If, on a Monthly Deduction Day, the cash surrender value is less than the
     Monthly Deduction Charge for the next policy month, how the policy will
     continue will depend on whether or not a Death Benefit Guarantee is in
     effect.

     If the Death Benefit Guarantee is in effect and there is no outstanding
     loan, the Guarantee will be invoked immediately on the Monthly Deduction
     Date. We will send a notification to your last known address that the Death
     Benefit Guarantee has been invoked and what Death Benefit Guarantee Amount
     will apply.

     If the Death Benefit Guarantee is in effect and there is an outstanding
     loan, you will be given the opportunity to repay the loan. We will notify
     you that if the loan, including any loan interest due, is not repaid within
     45 days, the Death Benefit Guarantee will be invoked, as described above,
     on the Monthly Deduction Date following the expiration of 45 days. If it is
     not repaid, the amount of any outstanding loan and loan interest will be
     deducted from the Death Benefit Guarantee Amount.

     Once the Death Benefit Guarantee is invoked, no further premium payments
     will be accepted, no further charges will be deducted, and no surrender,
     partial withdrawals, loans or changes of premium allocation election will
     be permitted. The Death Benefit Guarantee Amount will be paid when we
     receive proof that the Insured has died.


     If there is no Death Benefit Guarantee in effect, the policy will continue
     for a Late Period of 62 days after that Monthly Deduction Day on which the
     cash surrender value is insufficient to cover the monthly deduction charge.
     If we do not receive sufficient payment before the end of the Late Period,
     the policy will end and there will be no more benefits under the policy. To
     inform you of this event, we will mail a notice to you at your last known
     address at least 31 days before the end of the Late Period. We will also
     mail a copy of the notice to the last known address of any assignee on our
     records.


3.7  WHAT IF THE INSURED DIES DURING THE LATE PERIOD? If the Insured dies during
     the Late Period, we will pay the policy proceeds. However, these proceeds
     will be reduced by the amount of any unpaid loan, loan interest and any
     unpaid Monthly Deduction Charges for the full policy month or months that
     run from the beginning of the late period through the policy month in which
     the Insured died.


3.8  CAN YOU REINSTATE THE POLICY IF IT ENDS? Within 5 years after this policy
     has ended, you can apply to reinstate the policy if you did not surrender
     it and provided the Death Benefit Guarantee has not been invoked. When you
     apply for reinstatement, you must provide proof of insurability that is
     acceptable to us. However, if the required payment is made within 31 days
     after the end of the Late Period, no proof of insurability is required.


3.9  WOULD ADDITIONAL PREMIUMS BE REQUIRED TO REINSTATE THE POLICY? In order to
     reinstate this policy, a payment must be made in an amount that is
     sufficient to keep this policy in force for at least 3 months. Any
     surrender charges that apply after the reinstatement will be based on the
     same set of charges that existed prior to the lapse. Any unpaid loan must
     also be repaid, together with loan interest at 6% compounded once each year
     from the end of the late period to the date of reinstatement. If a policy
     loan interest rate of less than 6% is in effect when the policy is
     reinstated, the interest rate for any unpaid loan at the time of
     reinstatement will be the same as the policy loan interest rate. The
     effective date of reinstatement will be the Monthly Deduction Day on or
     following the date we approve the request for reinstatement. A Death
     Benefit Guarantee will not apply to a reinstated policy.


                                     PAGE 7
                                     0195-7


<PAGE>   13



                         SECTION FOUR - SEPARATE ACCOUNT


4.1 HOW IS THE SEPARATE ACCOUNT ESTABLISHED AND MAINTAINED? We have established
    and maintain the Separate Account under the laws of the State of Delaware.
    Any realized or unrealized income, net gains and losses from the assets of
    the Separate Account are credited or charged to it without regard to our
    other income, gains or losses. We put assets in the Separate Account for
    this policy, and we may also do the same for any other variable life
    insurance policies we may issue.


4.2 HOW ARE THE SEPARATE ACCOUNT ASSETS INVESTED? The Separate Account invests
    its assets in shares of one or more mutual funds. Fund shares are purchased,
    redeemed and valued on behalf of the Separate Account. The Separate Account
    is divided into Investment Divisions. We reserve the right to add, combine
    or eliminate any Investment Division of the Separate Account, subject to any
    required regulatory approvals.


4.3 TO WHOM DO THE ASSETS IN THE SEPARATE ACCOUNT BELONG? The assets of the
    Separate Account are our property. There are Separate Account assets which
    equal the reserves and other contract liabilities of the Separate Account.
    Those assets will not be chargeable with liabilities arising out of any
    other business we conduct. We reserve the right to transfer assets of an
    Investment Division, in excess of the reserves and other contract
    liabilities with respect to that Investment Division, to another Investment
    Division or to our General Account.


4.4 WHEN WILL THE ASSETS OF THE SEPARATE ACCOUNT BE VALUED? We will determine
    the value of the assets of the Separate Account on each day during which the
    New York Stock Exchange is open for trading. The assets of the Separate
    Account will be valued at fair market value, as determined in accordance
    with a method of valuation that we established in good faith.


4.5 CAN WE TRANSFER ASSETS OF THE SEPARATE ACCOUNT TO ANOTHER SEPARATE ACCOUNT?
    We reserve the right to transfer assets of the Separate Account, which we
    determine to be associated with the class of policies to which this policy
    belongs, to another separate account. If this type of transfer is made, the
    term "Separate Account", as used in this policy, shall then mean the
    separate account to which the assets were transferred.


4.6 WHAT OTHER RIGHTS DO WE HAVE? We also reserve the right, when permitted by
    law, to:

    (a) de-register the Separate Account under the Investment Company Act of
        1940;
    (b) manage the Separate Account under the direction of a committee or
        discharge such committee at any time;
    (c) restrict or eliminate any voting rights of policyowners or other persons
        who have voting rights as to the Separate Account;
    (d) combine the Separate Account with one or more other separate accounts;
        and
    (e) substitute shares of any other mutual fund for mutual fund shares held
        in any Investment Division with similar investment objectives.


4.7 CAN A CHANGE IN THE INVESTMENT OBJECTIVE OR STRATEGY OF THE SEPARATE ACCOUNT
    BE REQUIRED? When required by law or regulation, an investment objective of
    the Separate Account can be changed. It will only be changed if approved by
    the appropriate insurance official of the State of Delaware or deemed
    approved in accordance with such law or regulation. If so required, the
    request to obtain such approval will be filed with the insurance official of
    the state or district in which this policy is delivered.



                                     PAGE 8
                                     0195-8


<PAGE>   14



                 SECTION FOUR - SEPARATE ACCOUNT (CONTINUED)

4.8  IF THE ASSETS IN THE SEPARATE ACCOUNT BELONG TO US, WHAT DO YOUR FUNDS
     PURCHASE? Your interest of this policy in the Separate Account prior to the
     date on which the life insurance benefit becomes payable is represented by
     accumulation units. The number of accumulation units purchased in an
     Investment Division will be determined by dividing the part of any premium
     payment or the part of any transfer applied to that Investment Division, by
     the value of an accumulation unit for that Division on the transaction
     date. Payments allocated, transferred or otherwise added to the Investment
     Divisions will be applied to provide accumulation units in those Investment
     Divisions. Accumulation units are redeemed when amounts are loaned,
     transferred, surrendered or otherwise deducted. These transactions are
     called policy transactions.


4.9  WHAT ARE ACCUMULATION UNITS? Accumulation units are the accounting units
     used to calculate the values under this policy.


4.10 HOW IS THE VALUE OF AN ACCUMULATION UNIT DETERMINED? The value of an
     accumulation unit on any business day is determined by multiplying the
     value of that unit on the immediately preceding business day by the net
     investment factor for the valuation period. The valuation period is the
     period from the close of the immediately preceding business day to the
     close of the current business day. The net investment factor for this
     policy used to calculate the value of an accumulation unit in any
     Investment Division of the Separate Account for the valuation period is
     determined by dividing (a) by (b) and subtracting (c) from the result,
     where:

     (a)  is the sum of:

          (1) the net asset value of a fund share held in the Separate Account
          for that Investment Division determined at the end of the current
          valuation period, plus

          (2) the per share amount of any dividends or capital gain
          distributions made by the fund for shares held in the Separate Account
          for that Investment Division if the ex-dividend date occurs during the
          valuation period.

     (b)  is the net asset value of a fund share held in the Separate Account
          for that Investment Division determined as of the end of the
          immediately preceding valuation period.

     (c)  is a factor representing the mortality and expense risk charge. The
          maximum charge is shown on Policy Data page 2.1.

     The net investment factor may be greater or less than one; therefore, the
     value of an accumulation unit may increase or decrease.


4.11 CAN YOU TRANSFER FUNDS BETWEEN INVESTMENT DIVISIONS AND BETWEEN THE
     INVESTMENT DIVISIONS AND THE FIXED ACCOUNT? Transfers can be made between
     Investment Divisions of the Separate Account and between the Investment
     Divisions and the Fixed Account. We reserve the right to apply a charge,
     not to exceed $30, for each transfer after the first twelve in a given
     policy year. If this charge is assessed, it will be applied to the
     appropriate Investment Divisions, and/or the Fixed Account, on the basis of
     the amount of the total transfer that is allocated from each Investment
     Division, and/or the Fixed Account. We also reserve the right not to accept
     transfer instructions that are submitted by any person, asset allocation
     service, and/or market timing service on your behalf.




                                     PAGE 9
                                     0195-9


<PAGE>   15



                 SECTION FOUR - SEPARATE ACCOUNT (CONTINUED)


4.12 WHEN WILL THESE TRANSFERS TAKE EFFECT? Transfers between Investment
     Divisions (and also to and from the Fixed Account) will generally take
     effect as of the business day we receive, at our Home Office, your signed
     written request that gives us the facts we need. However, if we receive
     your request after the New York Stock Exchange is closed for trading, or on
     a day on which the New York Stock Exchange is not open for trading, the
     transfer will take effect on the next business day.


4.13 ARE THERE LIMITS ON THE AMOUNT YOU CAN TRANSFER BETWEEN INVESTMENT
     DIVISIONS? The minimum amount that can be transferred is the lesser of $500
     or the value of all remaining accumulation units in the Investment
     Division, unless we agree otherwise. The Investment Division from which the
     transfer is being made must maintain a minimum balance of $500 after the
     transfer is completed. If, after a transfer, the value of the remaining
     accumulation units in an Investment Division would be less than $500, we
     have the right to include that amount as part of the transfer.


                          SECTION FIVE - FIXED ACCOUNT


5.1  WHAT IS THE FIXED ACCOUNT? The Fixed Account is supported by assets of the
     Corporation that are not segregated in any of the separate accounts of New
     York Life Insurance and Annuity Corporation. Payments applied to and any
     amounts transferred to the Fixed Account are credited with interest using a
     fixed interest rate which we declare periodically. We will set this rate in
     advance at least annually. This rate will never be less than the rate shown
     on the Policy Data page. All payments applied to, or amounts transferred
     to, the Fixed Account thereafter receive the rate in effect at that time.
     The interest we credit may be different for loaned and unloaned amounts.


5.2  CAN TRANSFERS BE MADE FROM THE FIXED ACCOUNT TO THE SEPARATE ACCOUNT? Yes.
     The minimum amount which can be transferred is the lesser of: (a) $500, or
     (b) the accumulation value in the Fixed Account, unless we agree otherwise.
     However, if the values remaining in the Fixed Account after the transfer
     would be less than $500, we have the right to include that amount as part
     of the transfer. The sum of all such transfers in a policy year cannot
     exceed the greater of (a) 20% of the accumulation value in the Fixed
     Account at the beginning of that policy year, or (b) $5,000.


5.3  CAN TRANSFERS BE MADE TO THE FIXED ACCOUNT FROM THE SEPARATE ACCOUNT? Yes.
     The minimum amount which can be transferred from any one Investment
     Division is the lesser of: (a) $500, or (b) the value of all remaining
     accumulation units in that Investment Division, unless we agree otherwise.
     However, if the value remaining in an Investment Division after the
     transfer would be less than $500, we have the right to include that amount
     as part of the transfer.

     The sum of all such transfers in a policy year cannot exceed the greater of
     (a) 20% of the total value in the Separate Account at the beginning of that
     policy year, or (b) $5,000. However, this maximum limit only applies during
     any period when the interest rate being credited to the Fixed Account is
     equal to the guaranteed minimum rate shown on the Policy Data page. In
     addition, this maximum limit will not apply if the Insured was age 65 or
     older on the most recent policy anniversary. If, during a given policy
     year, this limit becomes effective, and you have already transferred more
     than 20% of the Separate Account value to the Fixed Account (or, if
     greater, $5,000), no additional transfers to the Fixed Account will be
     permitted during that policy year while the limit remains in effect.




                                     PAGE 10
                                     0195-10


<PAGE>   16


                       SECTION SIX - CASH VALUE AND LOANS

6.1  WHAT IS THE CASH VALUE OF THIS POLICY? The cash value of this policy at any
     time is equal to the total accumulation value of the portion of the cash
     value of this policy allocated to the Separate Account plus the portion of
     the cash value of this policy allocated to the Fixed Account.

6.2  CAN YOU SURRENDER THIS POLICY? At any time after this policy has cash
     value, and while the Insured is living, you can surrender it for its cash
     surrender value. The cash surrender value is equal to the cash value less
     any surrender charges which may apply, and less any unpaid loan and accrued
     interest. You can also elect to make a partial withdrawal for a percentage
     of the cash surrender value.

6.3  HOW IS THE SURRENDER CHARGE DETERMINED? For the number of years shown on
     the Surrender Charge page, a surrender charge will be assessed if the
     policy is surrendered. A surrender charge will also be assessed if a
     partial withdrawal is requested. The surrender charge will be based on a
     percentage of the lesser of the cash value or the total premiums paid and
     will never be greater than the maximum surrender charges shown on the
     Surrender Charge Data page. However, in any policy year, we will permit an
     amount to be withdrawn from the policy without incurring a surrender
     charge. This amount is equal to the greater of (a) 10% of the total
     premiums paid OR (b) 100% of the policy's cash value less the total
     premiums paid. The surrender charge applied to either a surrender or a
     partial withdrawal is calculated after the amount that may be withdrawn
     from the policy without incurring a charge is deducted.

6.4  HOW CAN FUNDS BE WITHDRAWN FROM THIS POLICY? You can request a partial
     withdrawal by sending us your signed written request that must be received
     while the Insured is living. The minimum amount that can be withdrawn is
     $500, unless we agree otherwise. The withdrawal will be made on a pro-rata
     basis from the Fixed Account and/or Investment Divisions, unless you direct
     otherwise. If the portion of your request for a partial withdrawal from the
     Fixed Account or Investment Division is greater than the amount in the
     Fixed Account and/or Investment Division, we will pay you the entire value
     of the Fixed Account and/or that Investment Division, less any surrender
     charge which may apply.

     We may charge a fee, not to exceed the lesser of $25, or 2% of the amount
     withdrawn, for processing a partial withdrawal. This fee will be deducted
     from the Fixed Account and/or Investment Divisions based on the withdrawal
     allocation specified or, if none, on a pro-rata basis. When you take a
     partial withdrawal, the cash value will be reduced by the amount of the
     withdrawal proceeds and any applicable surrender charge, as of the date we
     make the payment. In addition, the life insurance benefit may be reduced.
     (See Section 6.5.) A partial withdrawal may also reduce the Death Benefit
     Guarantee Amount. (See Section 6.6 for additional information.) A partial
     withdrawal will not be permitted if it would reduce the cash surrender
     value of the policy to less than $5,000, if the issue age of the Insured is
     age 0-17 or less than $10,000, if the issue age of the Insured is age 18
     and over. We reserve the right to limit partial withdrawals in the first
     policy year.

6.5  HOW WILL A WITHDRAWAL AFFECT YOUR POLICY'S VALUES? If the life insurance
     benefit equals the policy's Face Amount when you make a partial withdrawal,
     the Face Amount will be reduced by the amount of the partial withdrawal, on
     a dollar for dollar basis. The cash value will be reduced by the net amount
     of the withdrawal plus any applicable fees and charges.

     If the life insurance benefit exceeds the Face Amount before a partial
     withdrawal, then the Face Amount may be reduced depending on the level of
     cash value after the withdrawal. If the cash value after the withdrawal is
     greater than the current Face Amount divided by the applicable percentage
     shown on Policy Data Page 2.3, then the life insurance benefit will be
     reduced by the amount of the withdrawal plus any applicable fees and
     charges multiplied by the applicable percentage from Policy Data Page 2.3.
     If the cash value is less than the current Face Amount divided by the
     applicable percentage from Policy Data Page 2.3, then the Face Amount will
     be reduced by the difference between the cash value divided by the
     applicable percentage from Policy Data Page 2.3. In either case the cash
     value will be reduced by the amount of the partial withdrawal, on a dollar
     for dollar basis plus any applicable fees and charges.


                                     PAGE 11
                                     0195-11


<PAGE>   17


                  SECTION SIX - CASH VALUE AND LOANS (CONTINUED)

6.6  WILL A WITHDRAWAL AFFECT THE DEATH BENEFIT GUARANTEE? If there is a Death
     Benefit Guarantee in effect under this policy, a withdrawal will not cause
     it to terminate. However, the Death Benefit Guarantee Amount under the
     policy may decrease. After a withdrawal, a new Death Benefit Guarantee
     Amount may apply. It will be the lowest amount of a, b or c, where:

     (a)  The Initial Face Amount that would be purchased, assuming that the
          reduced policy values were equal to 100% of the Guideline Single
          Premium for a new policy at the Insured's attained age;
     (b)  The policy's Face Amount if reduced under the conditions in section
          6.5 above; or
     (c)  The Death Benefit Guarantee Amount applicable immediately before the
          withdrawal.

6.7  WHAT MONTHLY DEDUCTIONS ARE MADE AGAINST THE CASH VALUE? On each Monthly
     Deduction Day, the following deductions are made from the policy's cash
     value:

     (a) The monthly cost of insurance for the amount of the life insurance
     benefit in effect at that time;

     (b) A monthly administrative charge, based upon your cash value after the
     cost of insurance has been deducted, not to exceed the rate shown on the
     Policy Data page;

     (c) A Deferred Sales Expense Charge, based upon your cash value after the
     cost of insurance has been deducted, not to exceed the rate shown on the
     Policy Data page, for a 10 year period following each premium paid.

     The Monthly Deduction Day for this policy, which is shown on the Policy
     Data page, will be the same calendar day each month, as determined by the
     policy date. The first Monthly Deduction Day will be the first occurrence
     of this calendar day that falls on or after the issue date of the policy.
     However, if, on the issue date we have not yet received the initial premium
     payment for the policy, the first Monthly Deduction Day will be the first
     occurrence of this calendar day that falls on or after the date we receive
     such payment. If the policy date for this policy is earlier than the issue
     date, then deductions made on the first monthly Deduction Day will include
     the monthly deductions specified in (a) through (c) above. These deductions
     would have been made on each Monthly Deduction Day for the period from the
     policy date to the issue date as if the policy had been issued on the
     policy date. All monthly deductions are made in accordance with your
     expense allocation, if any. If no expense allocation is in effect, monthly
     deductions will be made on a pro-rata basis from each of the Investment
     Divisions and the Fixed Account.


6.8  HOW IS THE COST OF INSURANCE FOR THIS POLICY CALCULATED? The cost of
     insurance is calculated on each Monthly Deduction Day. The monthly cost of
     insurance is based on the net amount at risk. The monthly cost of insurance
     is equal to (1) multiplied by the result of (2) minus (3) where:

     (1) is the monthly cost of insurance rate per $1,000 of insurance;
     (2) is the number of thousands of life insurance benefit as of the Monthly
     Deduction Day divided by 1.00327; and
     (3) is the number of thousands of cash value as of the Monthly Deduction
     Day (before this cost of insurance and any applicable contract charge, are
     deducted).

6.9  WHAT IS THE COST OF INSURANCE RATE? The rates used to determine the cost of
     insurance for the initial face amount are based on the Insured's attained
     age, sex, and class of risk at the time the initial face amount took
     effect. For the initial face amount, the monthly cost of insurance rates
     will never exceed the maximum rates shown in the Table of Guaranteed
     Maximum Monthly Cost of Insurance Rates attached to this policy. The actual
     rate will be set by us, in advance, at least once a year. Any change in
     cost of insurance rates will be made on a uniform basis for Insureds in the
     same class, based on attained age, sex, and class of risk. Any change in
     these rates will be based on future expectations for items such as
     investment earnings, mortality, persistency and expenses.


                                     PAGE 12
                                     0195-12


<PAGE>   18
               SECTION SIX - CASH VALUE AND LOANS (CONTINUED)


6.10 WHAT IS THE LOAN VALUE OF THIS POLICY? Using this policy as sole security,
     you can borrow any amount up to the loan value of this policy. The loan
     value on any given date is equal to 90% of the cash surrender value.


6.11 WHAT HAPPENS WHEN YOU TAKE A LOAN? When a new loan is taken (including the
     situation where unpaid loan interest is charged as a new loan), a transfer
     is made from the Separate Account to the Fixed Account. This transfer is
     made so that, after the transfer, the amount in the Fixed Account, which is
     securing the outstanding loan(s), will equal 108% of the sum of the new
     loan and any previous unpaid loans. This percentage will be reduced
     accordingly if a lower loan interest rate is in effect at the time this
     transfer is made. For example, the percentage will be 106% if the loan
     interest rate is 6% at that time. This transfer will be made on a pro-rata
     basis from the various Investment Divisions. While a policy loan is
     outstanding, no partial withdrawals or transfers which would reduce the
     cash value of the Fixed Account below 108% (or any lower percentage that
     may be in effect at that time) of the outstanding loan are permitted. In
     addition, if any portion of a Monthly Deduction Charge would cause the
     amount in the Fixed Account to fall below the amount of the outstanding
     loan, we reserve the right to deduct that portion of the Monthly Deduction
     Charge on a pro-rata basis from the Investment Divisions instead.

     The amount in the Fixed Account that equals the amount of an unpaid loan
     will be credited with interest at a rate which will never be lower than the
     effective annual loan interest rate, less 2%. In no event will the rate
     credited to loaned amounts ever be less than the interest rate shown on the
     Policy Data page.

6.12 WHAT IS THE LOAN INTEREST RATE FOR THE POLICY? Unless we set a lower rate
     for any period, the effective annual loan interest rate is 8%, which is
     payable in arrears. Loan interest for the policy year in which a loan is
     taken will be due on the next policy anniversary. Loan interest accrues
     each day and is payable on the anniversary, on the date of death,
     surrender, or lapse, or on the date of a loan increase or loan repayment.
     Loan interest not paid when due will be charged as a new unpaid loan.


6.13 IF THE LOAN INTEREST RATE IS REDUCED, CAN IT SUBSEQUENTLY INCREASE? Yes. If
     we have set a rate lower than 8% per year, any subsequent increase in the
     interest rate will be subject to the following conditions:

     (1) The effective date of any increase in the interest rate shall not be
     earlier than one year after the effective date of the establishment of the
     previous rate.

     (2) The amount by which the interest rate can be increased will not exceed
     one percent per year, but the rate of interest shall in no event ever
     exceed 8%.

     (3) We will give notice of the interest rate in effect when a loan is made
     and when sending notice of loan interest due.

     (4) If a loan is outstanding 40 days or more before the effective date of
     an increase in the interest rate, we will notify you of that increase at
     least 30 days prior to the effective date of the increase.

     (5) We will give notice of any increase in the interest rate when a loan is
     made during the 40 days before the effective date of the increase.





                                     PAGE 13
                                     0195-13


<PAGE>   19
                SECTION SIX - CASH VALUE AND LOANS (CONTINUED)


6.14 HOW ARE LOAN REPAYMENTS CREDITED TO THE POLICY? All or part of an unpaid
     loan can be repaid before the Insured's death or before the policy is
     surrendered. When a loan repayment is received, we will first use that
     money to cancel any portion of the outstanding loan that was originally
     taken from the Fixed Account. Any remaining portion of the loan repayment
     will be allocated to the Separate Account in the same proportion as the
     amount of money you have in each Investment Division on the date of the
     loan repayment, unless you indicate otherwise and we agree.


6.15 WHAT HAPPENS IF A LOAN IS NOT REPAID? If a loan is outstanding when the
     life insurance benefit becomes payable, we will deduct the amount of the
     unpaid loan plus accrued interest from these proceeds. The cash surrender
     value reflects a deduction of any outstanding policy loan and accrued
     interest. In addition, it may happen in a given policy year that, based on
     the loan interest rate in effect when that policy year began (ignoring any
     subsequent increase in the rate during that policy year), any unpaid loan
     plus accrued interest exceeds the cash value of this policy less surrender
     charges. In that event, we will mail a notice to you at your last known
     address, and a copy to the last known assignee on our records. All
     insurance will end 31 days after the date on which we mail that notice to
     you if the excess of the unpaid loan plus accrued interest over the cash
     value less surrender charges is not paid within that 31 days. However, if a
     higher rate or rates take effect during the policy year, this policy will
     not end any sooner than it would have if the rate had not changed.

6.16 DOES A LOAN AFFECT THE DEATH BENEFIT GUARANTEE? Any loan taken under the
     conditions described above may affect the Death Benefit Guarantee as
     described in Section 1.4.


                   SECTION SEVEN - PAYMENT OF POLICY PROCEEDS


7.1  HOW WILL POLICY PROCEEDS BE PAID? The proceeds of this policy will be paid
     in one sum, or if elected, all or part of these proceeds can be placed
     under one or more of the options described in this section. If we agree,
     the proceeds may be placed under some other method of payment instead.

     Any life insurance proceeds paid in one sum will bear interest compounded
     each year from the Insured's death to the date of payment. We set the
     interest rate each year. This rate will be at least 3% per year, and will
     not be less than required by law.


7.2  HOW DO YOU ELECT AN OPTIONAL METHOD OF PAYMENT? While the Insured is
     living, you can elect or change an option. You can also elect or change one
     or more beneficiaries who will be the payee or payees under that option.

     After the Insured dies, any person who is to receive proceeds in one sum
     (other than an assignee) can elect an option and name payees. The person
     who elects an option can also name one or more successor payees to receive
     any amount remaining at the death of the payee. Naming these payees cancels
     any prior choice of successor payees. A payee who did not elect the option
     does not have the right to advance or assign payments, take the payments in
     one sum, or make any other change. However, the payees may be given the
     right to do one or more of these things if the person who elects the option
     tells us in writing and we agree.


7.3  HOW CAN AN OPTION BE CHANGED? If we agree, a payee who elects Option 1A, 1B
     or 2 may later elect to have any amount we still have, or the present value
     of any elected payments, placed under some other option described in this
     section.


                                     PAGE 14
                                     0195-14


<PAGE>   20
            SECTION SEVEN - PAYMENT OF POLICY PROCEEDS (CONTINUED)


7.4  WHO CAN BE NAMED PAYEES? Only individuals who are to receive payments on
     their own behalf may be named as payees or successor payees, unless we
     agree otherwise. We may require proof of the age or the survival of a
     payee.


7.5  WHAT HAPPENS IF THE PAYEE DIES BEFORE ALL PROCEEDS HAVE BEEN PAID? It may
     happen that when the last surviving payee dies, we still have an unpaid
     amount, or there are some payments that remain to be made. If so, we will
     pay the unpaid amount with interest to the date of payment, or pay the
     present value of the remaining payments, to that payee's estate in one sum.
     The present value of the remaining payments is based on the interest rate
     used to compute them, and is always less than their sum.


7.6  IS THERE A MINIMUM PAYMENT THE COMPANY WILL MAKE? When any payment under an
     option would be less than $100, we may pay any unpaid amount or present
     value in one sum.


7.7  WHAT ARE THE PROCEEDS AT INTEREST OPTIONS (1A AND 1B)? The policy proceeds
     can be left with us at interest. We will set the interest rate each year.
     This rate will be at least 3% per year.

     For the Interest Accumulation Option (Option 1A), we credit interest each
     year on the amount we still have. This amount can be withdrawn at any time
     in sums of $100 or more. We pay interest to the date of withdrawal on sums
     withdrawn.

     For the Interest Payment Option (Option 1B), we pay interest once each
     month, every 3 months, every 6 months, or once each year, as chosen, based
     on the amount we still have.


7.8  WHAT IS THE LIFE INCOME OPTION (2)? We make equal payments each month
     during the lifetime of the payee or payees. We determine the amount of the
     monthly payment by applying the policy proceeds to purchase a corresponding
     single premium life annuity policy which is being issued when the first
     payment is due. Payments are based on the appropriately adjusted annuity
     premium rate in effect at that time, but will not be less than the
     corresponding minimum shown in the Option 2 Table. These minimum amounts
     are based on the 1983 Table "a" with Projection Scale G, and with interest
     compounded each year at 3%.

     When asked, we will state in writing what the minimum amount of each
     monthly payment would be under this option. It is based on the sex and
     adjusted age of the payee or payees.

     To find the adjusted age in the year the first payment is due, we increase
     or decrease the payee's age at that time, as follows:

      1999-2005     2006-2015    2016-25        2026-35           2036 & later
      -------------------------------------------------------------------------
         +1             0          -1             -2                  -3




     We make a payment each month during the lifetime of the payee. Payments do
     not change, and are guaranteed for 10 years, even if that payee dies
     sooner.






                                     PAGE 15
                                     0195-15


<PAGE>   21




            SECTION SEVEN - PAYMENT OF POLICY PROCEEDS (CONTINUED)


------------------------------------------------------------------------------
   OPTION 2 TABLE
------------------------------------------------------------------------------

     Minimum Monthly Payment per $1,000 of Proceeds Guaranteed for 10 Years

<TABLE>
<CAPTION>
   Payee's
   Adjusted
   Age            MALE                          FEMALE
   ---------------------------------------------------------------------

<S>               <C>                           <C>
   60             4.46                          4.03
   61             4.55                          4.11
   62             4.66                          4.19
   63             4.76                          4.27
   64             4.87                          4.37
   65             4.99                          4.46
   66             5.11                          4.57
   67             5.24                          4.67
   68             5.38                          4.79
   69             5.52                          4.91
   70             5.66                          5.04
   71             5.81                          5.18
   72             5.96                          5.32
   73             6.12                          5.47
   74             6.28                          5.63
   75             6.45                          5.79
   76             6.61                          5.96
   77             6.78                          6.14
   78             6.96                          6.32
   79             7.13                          6.51
   80             7.30                          6.70
   81             7.46                          6.89
   82             7.63                          7.07
   83             7.78                          7.26
   84             7.93                          7.44
   85 & over      8.07                          7.62
</TABLE>



                       SECTION EIGHT - GENERAL PROVISIONS


8.1  WHAT CONSTITUTES THE ENTIRE CONTRACT? The entire contract consists of this
     policy, any attached riders or endorsements, and the attached copy of the
     application. Only our Chairman, President, Secretary, or one of our Vice
     Presidents is authorized to change the contract, and then, only in writing.
     No change will be made to this contract without your consent. No agent is
     authorized to change this contract.


8.2  HOW IMPORTANT IS THE INFORMATION YOU PROVIDE IN THE APPLICATION FOR THIS
     POLICY? In issuing this policy, we have relied on the statements made in
     the application. All such statements are deemed to be representations and
     not warranties. We assume these statements are true and complete to the
     best of the knowledge and belief of those who made them. No statement made
     in connection with the application will be used by us to void this policy
     unless that statement is a material misrepresentation and is part of the
     application.



                                     PAGE 16
                                     0195-16


<PAGE>   22



                SECTION EIGHT - GENERAL PROVISIONS (CONTINUED)

8.3  WILL WE BE ABLE TO CONTEST THIS POLICY? We will not contest the payment of
     the life insurance proceeds based on the initial face amount, after this
     policy has been in force during the lifetime of the Insured for 2 years
     from the date of issue


8.4  DOES THIS POLICY COVER SUICIDE OF THE INSURED? Suicide of the Insured,
     while sane or insane within 2 years of the date of issue, is not covered by
     this policy. In that event, this policy will end and the only amount
     payable will be the premiums paid to us, less any unpaid loan and any
     partial surrender benefits paid.


8.5  HOW ARE THE DATES REFERRED TO IN THIS POLICY MEASURED? Policy years,
     months, and anniversaries are measured from the policy date, unless
     otherwise stated.


8.6  HOW IS A PERSON'S AGE CALCULATED FOR THE PURPOSES OF THIS POLICY? When we
     refer to a person's age in this policy, we mean his or her age on the
     birthday that is nearest to the previous anniversary.


8.7  WHAT HAPPENS IF A PERSON'S AGE OR SEX HAS BEEN STATED INCORRECTLY? If we
     would pay too little or too much because the age or sex of the Insured is
     not correct as stated, we will adjust the proceeds, up or down, to reflect
     the correct age or sex. The amount of the death benefit shall be that which
     would be purchased by the initial premium paid at the correct age and sex.
     Any adjustment will maintain the choice of Guideline Single Payment
     Percentage indicated on the policy data page.


8.8  CAN PAYMENT OF A LOAN OR SURRENDER PROCEEDS BE DEFERRED? Generally, we will
     grant any loan, or pay any surrender proceeds or life insurance proceeds
     within 7 days after we receive all the requirements that we need. However,
     we may defer making any of these payments for any period during which the
     New York Stock Exchange is closed for trading (other than the usual weekend
     or holiday closings), or if the Securities and Exchange Commission
     restricts trading or has determined that a state of emergency exists. If
     so, it may not be practical for us to determine the investment experience
     of the Separate Account. In addition, we reserve the right to defer any of
     these payments based on funds allocated to the Fixed Account for as long as
     6 months.


8.9  CAN YOU ASSIGN OR TRANSFER THE POLICY? While the Insured is living, you can
     assign this policy, or any interest in it. If you do this, your interest,
     and anyone else's is subject to that of the assignee. As owner, you still
     have the rights of ownership which have not been assigned.


8.10 CAN THE ASSIGNEE CHANGE THE OWNER OR BENEFICIARY? An assignee cannot change
     the owner or beneficiary of this policy, and cannot elect or change an
     optional method of payment of proceeds. Any amount payable to the assignee
     will be paid in one sum.


8.11 HOW DO YOU ASSIGN THE POLICY? You must provide us with a copy of the
     assignment. We are not responsible for the validity of any assignment. Any
     assignment will be subject to any payment we make or other action we take
     before we record the assignment.




                                     PAGE 17
                                     0195-17


<PAGE>   23



                SECTION EIGHT - GENERAL PROVISIONS (CONTINUED)


8.12 ARE THE PAYMENTS MADE UNDER THIS POLICY PROTECTED AGAINST CREDITORS?
     Payments we make under this policy are, to the extent the law permits,
     exempt from the claims, attachments, or levies of any creditors.


8.13 TO WHOM SHOULD PAYMENTS FOR THIS POLICY BE MADE? Any payment made to us by
     check or money order must be payable to New York Life Insurance and Annuity
     Corporation. When asked, we will provide a countersigned receipt, signed by
     our President or Secretary, for any premium paid to us.


8.14 IS THIS POLICY SUBJECT TO ANY LAW? This policy is subject to all laws that
     apply.


8.15 ARE ANY DIVIDENDS PAYABLE ON THIS POLICY? This is a non-participating
     policy, on which no dividends are payable.


8.16 WILL YOU BE UPDATED REGARDING THE STATUS OF YOUR POLICY? Each policy year
     after the first, while this policy is in force and the Insured is living,
     we will send a written report to you within 30 days after the policy
     anniversary. It will show, as of that anniversary, the cash value, cash
     surrender value and the amount of any unpaid loan and accrued interest.
     This report will also give you any other facts required by state law or
     regulation.


8.17 CAN YOU EXCHANGE YOUR POLICY? Within 24 months of the issue date of this
     policy, you can exchange it for a new policy on the life of the Insured
     without evidence of insurability. In order to exchange this policy, we will
     require:
     (a)  that this policy be in effect on the date of exchange;
     (b)  repayment of any unpaid loan and accrued interest;
     (c)  an adjustment, if any, for premiums and cash values of this and the
          new policy.

     The date of exchange will be the later of: (a) the date you send us this
     policy along with a signed written request for an exchange; or (b) the date
     we receive at our Home Office, or at any other location that we indicate to
     you in writing, the necessary payment for the exchange.

     The benefits for the new policy will not reflect the investment experience
     of the Separate Account. The new policy will be on a permanent plan of
     insurance which we were offering for this purpose on the date of issue of
     this policy. You may choose for the new policy to have either a face amount
     equal to the face amount of this policy on the date of exchange or the same
     Death Benefit. The new policy will be based on the same issue age, sex and
     class of risk as this policy. All riders attached to this policy will end
     on the date of exchange, unless we agree otherwise.


8.18 WHAT IS THE BASIS USED FOR COMPUTATION OF POLICY VALUES? All cash surrender
     values and maximum cost of insurance rates referred to in this policy are
     based on the mortality table referred to on Policy Data page 2. This
     mortality table applies if the Insured is in a standard or better risk
     class. Separate scales of maximum cost of insurance rates apply to
     substandard risk classes.

     Continuous functions are used, with interest as stated in the Fixed Account
     section. The guaranteed minimum rate of return of the Fixed Account will
     yield values which are at least as much as the law requires. We have filed
     a statement with the insurance official in the state or district in which
     this policy is delivered. It describes, in detail, how we compute policy
     benefits and cash surrender values.


                                     PAGE 18
                                     0195-18

<PAGE>   24





<TABLE>
<S>                                                   <C>
NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION       MODIFIED SINGLE PREMIUM VARIABLE UNIVERSAL LIFE
                                                      INSURANCE POLICY

51 Madison Avenue                                     Variable Life Insurance Benefit -Modified Single
New York, N.Y.  10010                                 Premium Payments.  Proceeds Payable
                                                      at Insured's Death.
                                                      AMOUNT OF VARIABLE LIFE INSURANCE
                                                      OR CASH VALUE PROCEEDS MAY VARY,
                                                      REFLECTING INVESTMENT EXPERIENCE OF
                                                      SEPARATE ACCOUNT.
                                                      Limited Premium Flexibility - No
                                                      Premiums Payable on or After Age 100

A Stock Company Incorporated in Delaware              Policy is Non-Participating
</TABLE>




      301-95


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