EX-99.(5)(G) 8 dex995g.txt TIC GROUP DEFERRED VARIABLE ANNUITY APPLICATION (NEW YORK) L-22535NY 6-05 Exhibit 5(g) ================================================================================================================================ [LOGO OF THE TRAVELERS INSURANCE COMPANY] Group Deferred Variable Annuity Application The Travelers Insurance Company (New York) One Cityplace . Hartford, CT 06103-3415 ================================================================================================================================ Certificate Owner/Annuitant Information -------------------------------------------------------------------------------------------------------------------------------- Name SS# -------------------------------------------------------------------------------------------------------------------------------- Street Address Sex [ ] Male Date of Birth [ ] Female -------------------------------------------------------------------------------------------------------------------------------- City, State, Zip U.S. Citizen [ ] Y [ ] N If no, please indicate country of citizenship ================================================================================================================================ Beneficiary Information -------------------------------------------------------------------------------------------------------------------------------- Full Name (First, M.I., Last) SSN/TIN Relationship to Owner % to Receive -------------------------------------------------------------------------------------------------------------------------------- Primary -------------------------------------------------------------------------------------------------------------------------------- [ ] Primary [ ] Contingent -------------------------------------------------------------------------------------------------------------------------------- [ ] Primary [ ] Contingent -------------------------------------------------------------------------------------------------------------------------------- [ ] Primary [ ] Contingent -------------------------------------------------------------------------------------------------------------------------------- [ ] Primary [ ] Contingent ================================================================================================================================ Maturity Date: ____/____/_____ (Will be set to age 90 unless otherwise specified) ================================================================================================================================ Type of Plan (Please check only one) [ ] IRA Rollover [ ] Pension/Profit Sharing [ ] TSA ERISA [ ] 457 Def Comp Plan [ ] TSA [ ] Other_____________ ================================================================================================================================ Replacement Information Do you have any existing life insurance policies or annuity contracts? [ ] Yes [ ] No If yes, please provide details: Insurance Company Name: _____________________________ Contract Number: ______________________ Will the purchase of this annuity result in the replacement of any existing life insurance policy or annuity contract in this or any other company? [ ] Yes [ ] No If yes, provide the information below. Insurance Company Name: _____________________________ Contract Number: ______________________ Use the Special Requests section to provide additional insurance companies and contract numbers. Attach any required state replacement and/or 1035 exchange/transfer forms. State replacement forms may be required in certain states even if a replacement is not involved. ================================================================================================================================ L-22535NY *L22535NY* Order # L-22535NY 1 of 3; Rev. 6-05
================================================================================================================================ Allocation Schedule (total must equal 100%) -------------------------------------------------------------------------------------------------------------------------------- Name Code Pct Name Code Pct -------------------------------------------------------------------------------------------------------------------------------- AIM Capital Appreciation Portfolio KC % Pioneer Fund Portfolio UP % AIM V.I. Premier Equity Fund AL % Pioneer Mid Cap Value Portfolio FW % American Funds Global Growth Fund - Class 2 Shares IL % Pioneer Strategic Income Portfolio HP % American Funds Growth Fund - Class 2 Shares IG % Putnam VT Discovery Growth Fund - Class IB Shares OV % American Funds Growth-Income Fund - Class 2 Shares II % Putnam VT International Equity Fund - Class IB ON % Shares Capital Appreciation Fund (Janus) US % Putnam VT Small Cap Value Fund - Class IB Shares OP % Citistreet Diversified Bond Fund - Class I OB % Salomon Brothers Variable All Cap Fund - Class I AD % Citistreet International Stock Fund - Class I OI % Salomon Brothers Variable Investors Fund - Class I C2 % Citistreet Large Company Stock Fund - Class I OC % Salomon Brothers Variable Small Cap Growth Fund SS % - Class I Citistreet Small Company Stock Fund - Class I OE % Salomon Brothers Variable Total Return AE % Fund-Class 1 Credit Suisse Emerging Markets Portfolio AU % SB Adjustable Rate Income Portfolio BI % Delaware VIP REIT Series AQ % Smith Barney Aggressive Growth Portfolio SG % Delaware VIP Small Cap Value Series AP % Smith Barney Appreciation Portfolio 1N % Dreyfus VIF Appreciation Portfolio DP % Smith Barney Dividend Strategy Portfolio G1 % Dreyfus VIF Developing Leaders Portfolio DS % Smith Barney Fundamental Value Portfolio KR % Equity Income Portfolio (Fidelity) 4F % Smith Barney High Income Portfolio HH % Equity Index Portfolio - Class II GF % Smith Barney Intl All Cap Growth Portfolio HI % Federated Stock Portfolio 4D % Smith Barney Large Cap Growth Portfolio AB % Fidelity VIP Asset Manager Portfolio - FM % Smith Barney Premier Selection All Cap Growth P1 % Service Class 2 Portfolio Fidelity VIP Contrafund Portfolio-Service Class 2 FT % Smith Barney Small Cap Growth Opportunities C9 % Portfolio Fidelity VIP Dynamic Capital Appreciation D2 % Social Awareness Stock Portfolio (Smith Barney) SA % Portfolio -Service Class 2 Fidelity VIP Mid Cap Portfolio - Service Class 2 D1 % Strategic Equity Portfolio (Fidelity) HA % Franklin Mutual Shares Securities Fund - Class 2 R2 % Style Focus Series: Small Cap Growth Portfolio FY % Janus Aspen Balanced Portfolio - Service Shares BF % Style Focus Series: Small Cap Value Portfolio F0 % Janus Aspen Mid Cap Growth Portfolio - Service JA % Templeton Developing Markets Securities Fund - VQ % Shares Class 2 Janus Aspen Worldwide Growth Portfolio - Service WW % Templeton Foreign Securities Fund - Class 2 VG % Shares Large Cap Portfolio (Fidelity) 4G % Templeton Growth Securities Fund - Class 2 Q2 % Lazard Retirement Small Cap Portfolio RS % Travelers Convertible Securities Portfolio AF % Lord Abbett Growth & Income Portfolio FK % Travelers Disciplined Mid Cap Stock Portfolio 1M % Lord Abbett Mid Cap Value Portfolio FL % Travelers High Yield Bond Trust UB % Mercury Large Cap Core Portfolio DR % Travelers Managed Assets Trust UA % MFS Mid Cap Growth Portfolio DQ % Travelers Money Market Portfolio 1K % MFS Total Return Portfolio HT % Travelers Quality Bond Portfolio 4W % MFS Value Portfolio BD % Travelers U.S. Government Securities Portfolio GV % Mondrian International Stock Portfolio 4C % Van Kampen LIT Comstock Portfolio - Class II NJ % Shares Oppenheimer Main Street Fund/VA - Service Shares H2 % Van Kampen LIT Emerging Growth Portfolio - NY % Class II Shares PIMCO Real Return Portfolio - Adm Class PR % Van Kampen LIT Enterprise Portfolio - Class II NP % Shares PIMCO Total Return Portfolio PM % Wells Fargo Advantage Multi Cap Value Fund AT % Fixed Account (where approved) % % -------------------------------------------------------------------------------------------------------------------------------- TOTAL 100% ================================================================================================================================ PLEASE SEE PAGE 3 FOR REQUIRED SIGNATURES ================================================================================================================================ L-22535NY *L22535NY* Order # L-22535NY 2 of 3; Rev. 6-05
================================================================================================================================ Please check the following if choosing the Optional Death Benefit and Credit Endorsement: -------------------------------------------------------------------------------------------------------------------------------- [ ] Yes, I elect the Optional Death Benefit and Credit Endorsement (if not, you will receive the Standard Death Benefit) ================================================================================================================================ Dollar Cost Averaging/Systematic Withdrawal Programs (If checked, please attach completed form) -------------------------------------------------------------------------------------------------------------------------------- Dollar Cost Averaging [ ] Y [ ] N Systematic Withdrawal [ ] Y [ ] N ================================================================================================================================ Special Requests ================================================================================================================================ ================================================================================================================================ Disclosures and Acknowledgment -------------------------------------------------------------------------------------------------------------------------------- I/We understand the certificate will take effect when the first premium is received, and the data collection form is approved in the Home Office of the Company. All payments and values provided by the certificate applied for, when based on investment experience of a separate account, are variable and are not guaranteed as to a fixed dollar amount. No agent is authorized to make changes to the certificate or data collection form. I understand that the Company may amend this certificate to comply with changes in the Internal Revenue Code and related regulations. [ ] I ACKNOWLEDGE RECEIPT OF A CURRENT PROSPECTUS. -------------------------------------------------------------------------------------------------------------------------------- Certificate Owner's Signature City, State Where Signed (REQUIRED) Date -------------------------------------------------------------------------------------------------------------------------------- ================================================================================================================================ Representative Use Only -------------------------------------------------------------------------------------------------------------------------------- Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to criminal and civil penalties, including imprisonment, fines and denial of insurance benefits. I acknowledge that all data representations and signatures were recorded by me or in my presence in response to my inquiry and request and that all such representations and signatures are accurate and valid to the best of my knowledge and belief. Will the contract applied for replace any existing annuity or life insurance policy? [ ] Yes [ ] No -------------------------------------------------------------------------------------------------------------------------------- Representative's Name (Please print) Date -------------------------------------------------------------------------------------------------------------------------------- Representative's Signature SS# -------------------------------------------------------------------------------------------------------------------------------- Phone # Fax # License # -------------------------------------------------------------------------------------------------------------------------------- Broker/Dealer -------------------------------------------------------------------------------------------------------------------------------- For Citistreet Use Only (Circle one) Select One: [ ] A [ ] B [ ] C C / E / G / H ================================================================================================================================ L-22535NY *L22535NY* Order # L-22535NY 3 of 3; Rev. 6-05