Exhibit (5)(b)
ALLSTATE PROVIDER VARIABLE ANNUITY
(Flexible Premium Deferred Variable Annuity)
Issued by: Allstate Life Insurance Company of New York
Farmingville, New York
_______________________________________________________________________________
1. Owner(s)
Name___________________________ / / M / / F Birthdate __/__/__
Address________________________ Soc. Sec. No. ____-____-____
Street
_______________________________ Phone No. ( ) ____-____
City State Zip
Name___________________________ / / M / / F Birthdate __/__/__
Address________________________ Soc. Sec. No. ____-____-____
Street
_______________________________ Phone No. ( ) ____-____
City State Zip
_______________________________________________________________________________
2. Annuitant
Leave blank if annuitant is the same as sole Owner, otherwise complete.
Name_________________________________ / / M / / F Birthdate ___/___/___
Address _____________________________ Soc. Sec. No. ____-____-____
Street
_____________________________________
City State Zip
_______________________________________________________________________________
3. Beneficiary(ies)
Primary Contingent Name Relationship to Owner %
/ / / / ___________________ _____________________ ___
/ / / / ___________________ _____________________ ___
/ / / / ___________________ _____________________ ___
/ / / / ___________________ _____________________ ___
_______________________________________________________________________________
4. Purchase Payment/Variable Account Plan Options
Initial Purchase Payment $___________
Please assocate the above amount in $ or % (circle one) to the Variable
Sub-Accounts specified below.
Total must equal 100%
AIM V.I. Funds ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇ - Class 2 Funds ▇▇▇▇▇▇ ▇▇▇▇▇▇▇ Asset Management
//Balanced Fund ___ //Franklin Small Cap Fund ___ //UIF Equity Growth Portfolio ___
//Diversified Income Fund ___ //Mutual Shares Securities ___ //UIF Fixed Income Portfolio ___
//Government Securities Fund ___ //▇▇▇▇▇▇▇▇▇ Developing //UIF Global Equity Portfolio ___
//Growth Fund ___ Markets Securities ___ //UIF Mid Cap Value Portfolio ___
//Growth and Income Fund ___ //▇▇▇▇▇▇▇▇▇ Growth //UIF Value Portfolio ___
//International Equity Fund ___ Securities ___
//Value Fund ___ //▇▇▇▇▇▇▇▇▇ International ▇▇▇▇▇▇▇▇▇▇▇ Funds
Securites ___ //Aggressive Growth Fund/VA ___
Dreyfus //Capital Appreciation
//The Dreyfus ▇▇▇▇▇▇▇ ▇▇▇▇▇ VIT Fund/VA ___
Socially Responsible //Capital Growth Fund ___ //Global Securities Fund/VA ___
Growth Fund, Inc. ___ //CORE* Small Cap Equity Fund ___ //Main Street Growth and
//Stock Index Fund ___ //CORE* U.S. Equity Fund ___ Income Fund/VA ___
//VIF Growth & Income ___ //Global Income Fund ___ //Strategic Bond Fund/VA ___
//VIF Money Market ___ //International Equity Fund ___
MVA Fixed Account
Fidelity MFS //1 Year Guarantee Period ___
//VIP Contrafund* ___ //Emerging Growth Series ___ //3 Year Guarantee Period ___
//VIP Equity Income ___ //Growth with Income Series ___ //5 Year Guarantee Period ___
//VIP Growth ___ //New Discovery Series ___ //7 Year Guarantee Period ___
//VIP High Income ___ //Research Series ___ //10 Year Guarantee Period ___
_______________________________________________________________________________
5. Tax Qualified Plan
/ / Yes / / No (If Yes, complete the following.)
/ / Traditional IRA or / / ▇▇▇▇ ▇▇▇ / / SEP / / Other ____________
/ / Rollover / / Transfer / / Contribution $_____Contribution Year ___
_______________________________________________________________________________
6. Dollar-Cost Averaging Program
/ / Money Market
Please transfer $_____ from the Money Market Portolio each month starting
___/___/___.
Please allocate the amount to the sub-accounts specified below:
Note: Dollar-Cost Averaging into the Fixed Accounts is not available.
This agreement ends automatically when the account value in the sub-account
selected above has been depleted.
Sub-account % or $ Sub-account % or $
___________________ ______ ___________________ ______
___________________ ______ ___________________ ______
___________________ ______ ___________________ ______
___________________ ______ ___________________ ______
___________________ ______ ___________________ ______
Total = 100%
______________________________________________________________________________
7. Automatic Portfolio Rebalancing Program
On a quarterly basis, please complete a transfer between the Variable
Sub-accounts to achieve the ending percent allocation below:
None of the money allocated to the MVA Fixed Accounts will be transferred as
a result of this rebalancing program.
Please begin the Rebalancing Programon ___/___/___.
/ / Keep in effect until notified otherwise. / / Stop the Rebalancing Program
on ___/___/___.
Sub-account % Sub-account %
___________________ ______ ___________________ ______
___________________ ______ ___________________ ______
___________________ ______ ___________________ ______
___________________ ______ ___________________ ______
___________________ ______ ___________________ ______
______________________________________________________________________________
8. Automatic Additions Program
I authorize Allstate Life Insurance Company of New York to begin automatic
debits from the account designated below. The funds withdrawn from this account
shall be added to my annuity as an Automatic Addition (Purchase Payment) to the
sub-accounts specified below:
The debit amount is $_______. The debits sould begin in ____________.
(Month)
Debit my (check one) / / Checking Account / / Savings Account
on the (check one) / / 5th day or / / 25th day of each (check one) / / Month
or / / Quarter
Financial Institution _______________________________
Address _____________________________________________
ABA No. __________________________ Acct. No. _______________
Please allow three business days for the payment ot be credited to you annuity.
A VOIDED BLANK CHECK FOR THE ABOVE ACCOUNT MUST BE ATTACHED.
/ / Keep the Automatic Addition Program in effect until notified otherwise.
/ / Stop the Automatic Addition Program on ___/___/___.
Sub-account % or $ Sub-account % or $
___________________ ______ ___________________ ______
___________________ ______ ___________________ ______
___________________ ______ ___________________ ______
___________________ ______ ___________________ ______
___________________ ______ ___________________ ______
______________________________________________________________________________
9. Systematic Withdrawal Authorization
I hereby authorize Allstate Life Insurnace Company of New York to make
withdrawals of the amount indicated below. I understand that withdrawals may
result in taxable income and, prior to owner's agre of 59-1/2, may be subject to
a 10% federal penalty. The Allstate Provider Variable Anniuty allows up to 15%
of purchse payments to be withdrawn each contract year. Withdrawals that exceed
15% may be assessed a withdrawal charge.
Please check frequency: / / Monthly / / Quarterly / / Semi-Annually
/ / Annually
StartDate: ___/___/___
/ / Gross partial withdrawal. The check may differ from the requested amount
due to applicable charges, adjustments or income tax withholding.
Gross Amount: $________.
/ / Net partial withdrawal. The check amount will equal the requested amount.
The Account Value will be reduced to reflect the amount received, as well
as applicable charges, adjustments and income tax withholding. Net
Amount: $__________.
Specify percentage or dollar amount to be withdrawn from each sub-account.
Sub-account % or $ Sub-account % or $
___________________ ______ ___________________ ______
___________________ ______ ___________________ ______
___________________ ______ ___________________ ______
___________________ ______ ___________________ ______
___________________ ______ ___________________ ______
______________________________________________________________________________
9a. Withholding Election (Required)
/ / I do want to have ____% federal tax withheld. If no percentage is
indicated, 10% will be withheld.
/ / I do not want to have federal income tax withheld. Federal income tax will
be withheld unless this box is checked.
_______________________________________________________________________________
9b. Direct Deposit
Please deposit the above amount to: (check one) / / Checking Account
/ / Savings Account
Financial Institution _______________________________________
Address _____________________________________________________
ABA No. ____________________ Acct. No._______________________
Please allow two business days for the payment to be credited to your account.
A VOIDED BLANK CHECK FOR THE ABOVE ACCOUNT MUST BE ATTACHED
If, instead of a direct deposit, you wish to have a check mailed to you,
complete the following:
▇▇▇▇▇'s Name ___________________________ Acct. No.* ____________________
*if applicable
Address ________________________________________________________________
_______________________________________________________________________________
Notice of Withholding
You may elect not to have federal income tax withheld from the taxable portion
of your distribution by contacting Allstate Life Insurance Company of New York.
A withholding election will remain in effect until revoked, which you may do at
any time. If you do not make payments of estimated tax, and do not have enough
tax withheld, you may be subject to penalties under the estimated tax rules. CA
residents: If you choose to have federal income tax withheld, the laws of your
state require that state income tax be withheld unless you specifically elect
not to have state income tax withheld. You may contact us at any time to change
or revoke your election. The withholding rate on withdrawals which are not
distributions from a plan qualified under Internal Revenue Code Sections 401 or
403(b) is 10% of the taxable portion of the withdrawal. Distributions from a
plan qualified under Internal Revenue Code Section 41 or 403(b) may be subject
to 20% withholding. If you request such a distribution, you will receive a
notice outlining the applicable rules.
______________________________________________________________________________
10. Special Instructions
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
______________________________________________________________________________
11. Signatures(s)
If this application is declined, Allstate life Insurance Company of New York
will have no liability except to return the purchase payment. I understand that
any distribution from a Fixed Account prior to the end of a rate guarantee
period may be subject to a Market Value Adjustment which may be negative or
positive. I understand that annuity values and income payments based on the
investment experience of a variable account are variable and are not guaranteed
as to dollar amount. I have received the current prospectus for this variable
annuity. I represent that the information I have provided is complete and true
to the best of my knowledge and belief.
Signed at ______________________________________ Date ___/___/___
State
Owner(s) Signature(s) _______________________/___________________
______________________________________________________________________________
12. Agent Use Only
Will the annuity applied for replace or change any existing annuity or life
insurance? / / Yes / / No
Agent Name (Please print) ______________________ Phone No. ( ) ____-____
Agent Signature _____________________________ Soc. Sec. No. _____________
______________________________________________________________________________
INSURANCE DEPARTMENT OF THE STATE OF NEW YORK -- APPENDIX 11
DEFINITION OF REPLACEMENT
IN ORDER TO DETERMINE WHETHER YOU ARE REPLACING OR OTHERWISE CHANGING THE STATUS
OF EXISTING LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS, AND IN ORDER TO
RECEIVE THE VALUABLE INFORMATION NECESSARY TO MAKE A CAREFUL COMPARISON IF YOU
ARE CONTEMPLATING REPLACEMENT, THE AGENT IS REQUIRED TO ASK YOU THE FOLLOWING
QUESTIONS AND EXPLAIN ANY ITEMS THAT YOU DO NOT UNDERSTAND.
AS PART OF YOUR PURCHASE OF A NEW LIFE INSURANCE POLICY OR A NEW ANNUITY
CONTRACT, HAS EXISTING COVERAGE BEEN, OR IS IT LIKELY TO BE:
(1) LAPSED, SURRENDERED, PARTIALLY SURRENDERED, FORFEITED, ASSIGNED TO THE
INSURER REPLACING THE LIFE INSURANCE POLICY OR ANNUITY CONTRACT, OR
OTHERWISE TERMINATED?
YES ____ NO ____
(2) CHANGED OR MODIFIED INTO PAID-UP INSURANCE; CONTINUED AS EXTENDED TERM
INSURANCE OR UNDER ANOTHER FORM OF NONFORFEITURE BENEFIT; OR OTHERWISE
REDUCED IN VALUE BY THE USE OF NONFORFEITURE BENEFITS, DIVIDEND
ACCUMULATIONS, DIVIDEND CASH VALUES OR OTHER CASH VALUES?
YES ____ NO ____
(3) CHANGED OR MODIFIED SO AS TO EFFECT A REDUCTION EITHER IN THE AMOUNT OF THE
EXISTING LIFE INSURANCE OR ANNUITY BENEFIT OR IN THE PERIOD OF TIME THE
EXISTING LIFE INSURANCE OR ANNUITY BENEFIT FILL CONTINUE IN FORCE?
YES ____ NO ____
(4) REISSUED WITH A REDUCTION IN AMOUNT SUCH THAT ANY CASH VALUES ARE RELEASED,
INCLUDING ALL TRANSACTIONS WHEREIN AN AMOUNT OF DIVIDEND ACCUMULATIONS OR
PAID-UP ADDITIONS IS TO BE RELEASED ON ONE OR MORE OF THE EXISTING
POLICIES?
YES ____ NO ____
(5) ASSIGNED AS COLLATERAL FOR A LOAN OR MADE SUBJECT TO BORROWING OR
WITHDRAWAL OR ANY PORTION OF THE LOAN VALUE, INCLUDING ALL TRANSACTIONS
WHEREIN ANY AMOUNT OF DIVIDEND ACCUMULATIONS OR PAID-UP ADDITIONS IS TO BE
BORROWED OR WITHDRAWN ON ONE OR MORE EXISTING POLICIES?
YES ____ NO ____
(6) CONTINUED WITH A STOPPAGE OF PREMIUM PAYMENTS OR REDUCTION IN THE AMOUNT OF
PREMIUM PAID?
YES ____ NO ____
IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, A REPLACEMENT AS DEFINED
BY NEW YORK INSURANCE DEPARTMENT REGULATION NO. 60 HAS OCCURRED OR IS LIKELY TO
OCCUR AND YOUR AGENT IS REQUIRED TO PROVIDE YOU WITH A COMPLETED DISCLOSURE
STATEMENT AND THE IMPORTANT NOTICE REGARDING REPLACEMENT OR CHANGE OF LIFE
INSURANCE POLICIES OR ANNUITY CONTRACTS.
Date: ______________________ Signature of Applicant:___________________
Date: ______________________ Signature of Applicant:___________________
TO THE BEST OF MY KNOWLEDGE, A REPLACEMENT IS INVOLVED IN THIS TRANSACTION:
YES ______ NO _______
Date: ______________________ Signature of Agent: ______________________
Note to agent: copies must be given to the customer and the company issuing new
policy.
Mailing Address: Allstate Life Insurance Company of
New York
P.O. Box 94038
Palatine, Illinois 60094-4038
Overnight Address: ▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇
▇▇▇▇▇ ▇▇▇
▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇▇▇▇▇
Sales Support: AFDinc: ▇-▇▇▇-▇▇▇-▇▇▇▇
Customer Service: ▇-▇▇▇-▇▇▇-▇▇▇▇
The Allstate Provider Variable Annuity is a flexible premium deferred variable
annuity issued by Allstate Life Insurance Company of New York and underwritten
by ALFS, Inc. Both are subsidiary affiliates of Allstate Life Insurance Company,
headquartered in Northbrook, Illinois. The Allstate Provider Variable annuity is
sold through agreements with unaffiliated registered representatives,
broker-dealers, and bank employees who are licensed annuity representatives.
Please read the prospectus carefully before you invest or send money.
IMSA
Insurance
Marketplace
Standards
Association
Membership
Promotes
Ethical Market
Conduct For
Individual Life
Insurance and
Annuities
NYLR1596
Exhibit 5(c)
Flexible Premium Deferred Variable Annuity
Issued by: Allstate Life Insurance Company of New York, Farmingville, NY
Mail check (payable to) and application to:
Allstate Life Insurance Company of New York
P.O. Box 94038, Palatine, IL ▇▇▇▇▇-▇▇▇▇, Telephone No.: ▇▇▇-▇▇▇-▇▇▇▇
Send overnight mail to:
Allstate Life Insurance Company of New York
▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇
______________________________________________________________________________
1. OWNER: If no Annuitant is specified in Section 3, the Owner will be the
Annuitant.
______________________________________________________________________________
/ / Male / / Female Birth Date ___/___/___ Phone ( ) ___-____
Name _______________________________ SS#/TIN _____________________
Street _____________________City____________State___Zip______ County________
______________________________________________________________________________
2. JOINT OWNER: If any.
______________________________________________________________________________
/ / Male / / Female Birth Date ___/___/___ Phone ( ) ___-____
Name _______________________________ SS#/TIN _____________________
Street _____________________City____________State___Zip______ County________
Relationship to Other Owner ______________________________________
______________________________________________________________________________
3. ANNUITANT: Leave blank if Annuitant is same as sole owner in Section 1.
______________________________________________________________________________
/ / Male / / Female Birth Date ___/___/___ Phone ( ) ___-____
Name _______________________________ SS#/TIN _____________________
Relationship to Owner _______________________________________________
Street _____________________City____________State___Zip______ County________
_____________________________________________________________________________
4. BENEFICIARY(IES): To receive Dath Benefit if no surviving Owner(s)
_____________________________________________________________________________
Primary __________________________ Relationship to Owner(s)__________________
Soc. Sec. No. ____________________ Birth Date __/__/__ Percentage _____%
Contingent _______________________ Relationship to Owner(s)__________________
Soc. Sec. No. ____________________ Birth Date __/__/__ Percentage _____%
______________________________________________________________________________
5. TAX-QUALIFIED PLANS:
______________________________________________________________________________
// Non-qualified // Traditional IRS // SEP-IRA // ▇▇▇▇ ▇▇▇ // 401(k)
// 401(a) // 403(b) // Rollover // Transfer
Tax year for which initial contribution is being made _______ // Other _______
Contribution $______________
______________________________________________________________________________
6. INVESTMENT SELECTION: Please check selected investment choice(s) and indicate
whole percentage allocations. The initial premium will be allocated as selected
here.
______________________________________________________________________________
Initial Premium Payment $___________________
Variable Sub-Accounts
//AIM VI Growth & Income ____% //Fidelity VIPII Index 500 ____% //MFS Growth with Income ___%
//AIM VI Value ____% //Fidelity VIP High Income ____% //MFS New Discovery ____%
//AIM VI Capital Appreciation ____% //Fidelity VIPII Investment Grade Bond ___% //MFS Bond ____%
//AIM VI International Equity ____% //▇▇▇▇▇▇▇▇▇▇▇ Capital Appreciation/VA ____% //MFS High Income ____%
//AIM VI Diversified Income ____% //▇▇▇▇▇▇▇▇▇▇▇ Small Cap Growth/VA ____% //▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ____%
//Fidelity VIPII Contrafund ____% //▇▇▇▇▇▇▇▇▇▇▇ Global Securities/VA ____% //▇▇▇ ▇▇▇▇▇▇ Emerging Growth ____%
//Fidelity VIP Growth ____% //▇▇▇▇▇▇▇▇▇▇▇ High Income/VA ____% //▇▇▇ ▇▇▇▇▇▇ Domestic Income ____%
//Fidelity VIP Overseas ____% //▇▇▇▇▇▇▇▇▇▇▇ Bond/VA ____% //▇▇▇ ▇▇▇▇▇▇ Money Market ____%
Fixed Accounts
// 1 Year Guarantee Period ____%
// 3 Year Guarantee Period ____%
// 5 Year Guarantee Period ____%
// 7 Year Guarantee Period ____%
// 10 Year Guarantee Period ____%
Total 100%
______________________________________________________________________________
7. OPTIONAL PROGRAMS:
______________________________________________________________________________
/ / AUTOMATIC PORTFOLIO REBALANCING PROGRAM
Frequency: // Monthly // Quarterly // Semi-Annual // Annual
____% in subaccount ___________ ____% in subaccount _________ ____% in subaccount _______
____% in subaccount ___________ ____% in subaccount _________ ____% in subaccount _______
____% in subaccount ___________ ____% in subaccount _________ ____% in subaccount _______
/ / DOLLAR COST AVERAGING PROGRAM
Transfer from (select investment option) Transfer to (select investment option) Percent per transfer
_______________________________________ ______________________________________ _______________%
_______________________________________ ______________________________________ _______________%
_______________________________________ ______________________________________ _______________%
_______________________________________ ______________________________________ _______________%
_______________________________________ ______________________________________ _______________%
_______________________________________ ______________________________________ _______________%
_______________________________________ ______________________________________ _______________%
_______________________________________ Note: TOTAL MUST= 100% ____ TOTAL = _______%
______________________________________________________________________________
8. REPLACEMENT(S):
______________________________________________________________________________
A. Will the annuity applied for replace one or more existing annuity or life
insurance contracts? ..........................// YES // NO
If "YES," give name of company, policy number, policy issue date and cost basis
amount: ______________________________________________________________________
B. Have you purchased another annuity during the current calendar year?
..........................// YES // NO
C. Do you or any joint owner currently own an annuity issued by the Insurer?
..........................// YES // NO
// RECEIPT OF A VARIABLE ANNUITY AND FUND PROSPECTUS(S) IS HEREBY ACKNOWLEDGED.
(If not checked, the appropriate prospectus will be mailed to you.)
_______________________________________________________________________________
9. AUTHORIZATIONS:
_______________________________________________________________________________
I/We hereby declare to the best of my/our knowledge, and belief, all statements
and answers are true and correct. I/WE UNDERSTAND THAT ANNUITY PAYMENTS OR
SURRENDER VALUES, WHEN BASED UPON THE INVESTMENT EXPERIENCE OF A SEPARATE
ACCOUNT, ARE VARIABLE AND NOT GUARANTEED AS TO A FIXED DOLLAR AMOUNT. I
UNDERSTAND THAT ANY DISTRIBUTION FROM A FIXED ACCOUNT PRIOR TO THE END OF A RATE
GUARANTEE PERIOD MAY BE SUBJECT TO A MARKET VALUE ADJUSTMENT.
A copy of this application signed by the Agent will be the receipt for the first
purchase payment. If the Insurer declines this application, the Insurer will
have not liability except to return the first purchase payment.
I have read the above statements and represent that they are complete and true
to the best of my knowledge and belief. I agree that this application shall be a
part of the annuity issued by the Insurer. By accepting the annuity issued, I
agree to any additions or corrections to this application. The Insurer will
obtain agreement from me for any change in investment allocations, benefits,
type of plan or birthdates.
Owner's Signature ____________ Dated At______________ Dated On __/__/__
City State
Joint Owner's Signature ____________ Dated At______________ Dated On __/__/__
City State
TO THE AGENT: Will this annuity applied for replace or change any existing
annuity of life insurance? ..............// YES // NO
Licensed Writing Agent Name (PRINT) ____________ Agent Signature______________
Agent Number _____________________ Region ______ Terr._____ Dist. ______
Agent's Phone Number ( ) ______________
Licensed Participating Agent Name (PRINT) ______ Agent Signature _____________
Agent Number _____________________ Region ______ Terr._____ Dist. ______
Agent's Phone Number ( ) _______________
______________________________________________________________________________
______________________________________________________________________________
FOR AGENT USE ONLY:
Contact you home office for program information: // Option A // Option B
NOTE: If no Option is give, "Option A" will be designated.
______________________________________________________________________________
NYLR332
INSURANCE DEPARTMENT OF THE STATE OF NEW YORK -- APPENDIX 11
DEFINITION OF REPLACEMENT
IN ORDER TO DETERMINE WHETHER YOU ARE REPLACING OR OTHERWISE CHANGING THE STATUS
OF EXISTING LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS, AND IN ORDER TO
RECEIVE THE VALUABLE INFORMATION NECESSARY TO MAKE A CAREFUL COMPARISON IF YOU
ARE CONTEMPLATING REPLACEMENT, THE AGENT IS REQUIRED TO ASK YOU THE FOLLOWING
QUESTIONS AND EXPLAIN ANY ITEMS THAT YOU DO NOT UNDERSTAND.
AS PART OF YOUR PURCHASE OF A NEW LIFE INSURANCE POLICY OR A NEW ANNUITY
CONTRACT, HAS EXISTING COVERAGE BEEN, OR IS IT LIKELY TO BE:
(1) LAPSED, SURRENDERED, PARTIALLY SURRENDERED, FORFEITED, ASSIGNED TO THE
INSURER REPLACING THE LIFE INSURANCE POLICY OR ANNUITY CONTRACT, OR
OTHERWISE TERMINATED?
YES ____ NO ____
(2) CHANGED OR MODIFIED INTO PAID-UP INSURANCE; CONTINUED AS EXTENDED TERM
INSURANCE OR UNDER ANOTHER FORM OF NONFORFEITURE BENEFIT; OR OTHERWISE
REDUCED IN VALUE BY THE USE OF NONFORFEITURE BENEFITS, DIVIDEND
ACCUMULATIONS, DIVIDEND CASH VALUES OR OTHER CASH VALUES?
YES ____ NO ____
(3) CHANGED OR MODIFIED SO AS TO EFFECT A REDUCTION EITHER IN THE AMOUNT OF THE
EXISTING LIFE INSURANCE OR ANNUITY BENEFIT OR IN THE PERIOD OF TIME THE
EXISTING LIFE INSURANCE OR ANNUITY BENEFIT FILL CONTINUE IN FORCE?
YES ____ NO ____
(4) REISSUED WITH A REDUCTION IN AMOUNT SUCH THAT ANY CASH VALUES ARE RELEASED,
INCLUDING ALL TRANSACTIONS WHEREIN AN AMOUNT OF DIVIDEND ACCUMULATIONS OR
PAID-UP ADDITIONS IS TO BE RELEASED ON ONE OR MORE OF THE EXISTING
POLICIES?
YES ____ NO ____
(5) ASSIGNED AS COLLATERAL FOR A LOAN OR MADE SUBJECT TO BORROWING OR
WITHDRAWAL OR ANY PORTION OF THE LOAN VALUE, INCLUDING ALL TRANSACTIONS
WHEREIN ANY AMOUNT OF DIVIDEND ACCUMULATIONS OR PAID-UP ADDITIONS IS TO BE
BORROWED OR WITHDRAWN ON ONE OR MORE EXISTING POLICIES?
YES ____ NO ____
(6) CONTINUED WITH A STOPPAGE OF PREMIUM PAYMENTS OR REDUCTION IN THE AMOUNT OF
PREMIUM PAID?
YES ____ NO ____
IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, A REPLACEMENT AS DEFINED
BY NEW YORK INSURANCE DEPARTMENT REGULATION NO. 60 HAS OCCURRED OR IS LIKELY TO
OCCUR AND YOUR AGENT IS REQUIRED TO PROVIDE YOU WITH A COMPLETED DISCLOSURE
STATEMENT AND THE IMPORTANT NOTICE REGARDING REPLACEMENT OR CHANGE OF LIFE
INSURANCE POLICIES OR ANNUITY CONTRACTS.
Date: ______________________ Signature of Applicant:___________________
Date: ______________________ Signature of Applicant:___________________
TO THE BEST OF MY KNOWLEDGE, A REPLACEMENT IS INVOLVED IN THIS TRANSACTION:
YES ______ NO _______
Date: ______________________ Signature of Agent: ______________________
Note to agent: copies must be given to the customer and the company issuing new
policy.
NYLR310A