Exhibit (e)(1)

Individual Life Insurance Application

New York Life Insurance Company

New York Life Insurance and Annuity Corporation

(A Delaware Corporation)

NYLIFE Insurance Company of Arizona (Not Licensed in Every State)

213-500

The Company You Keep®

NEW YORK LIFE INSURANCE COMPANY

NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION (A Delaware Corporation) NYLIFE INSURANCE COMPANY OF ARIZONA (Not Licensed in Every State)

Attending Physician’s Statement/Expedite Order Form

Optional form to submit with the application Part I

If your client requires an age and amount APS or has a known medical history, expedite the ordering of the APS by completing this form.

Full Name of Proposed Insured

Date of Birth Social Security Number

List name, address and phone number of primary care physician visited in the past 5 years:

Medication or

Provider Name, Address and Phone Number Reason for Visit Date Treatment Provided

List name, address and phone number of all other physicians, and of health care providers, medical facilities, or hospitals visited or referred to in the past 5 years:

Medication or

Provider Name, Address and Phone Number Reason for Visit Date Treatment Provided

Additional Details (results, diagnostic tests, etc.):

List all medications, both prescribed and over the counter, not listed above, taken on a regular basis within the last 12 months:

Medication Reason Date

AGENT STATEMENT

Not Part of the Application

Primary Insured

First Name Middle Name Last Name

1. Licensing and Jurisdiction

Plan             Date of application             /            /            

In which state did the Applicant sign the application?            In which state does the Applicant reside?             In which state is the Applicant employed?             Was the Applicant’s signature obtained by mail? Yes No In which state did the Primary Insured sign the application?             In which state does the Primary Insured reside?             Was the Primary Insured’s signature obtained by mail? Yes No In which state does the Owner reside?             In which state will the policy be delivered?            Will the policy be delivered by mail? Yes No

2. Customer Verification (Complete for all Owners)

Per Federal Regulations, please affirm which acceptable proof of identification was presented by the Owner(s) of the contract at the time of application. Documentation must not be expired. For an Individual, documentation must be an original—a photocopy of the document is NOT valid.

Individual: Driver’s License Passport Government or State Issued Photo ID

Must verify: Number             Issuing Authority (Country or State)             Expiration Date            /            /            

Business, Partnership, Corporation or Trust: Government Issued Business License Partnership Agreement Certified Articles of Incorporation Trust Agreement Date of Document             /            /            

To whom was the proof of identification presented? Agent Licensed Service Assistant

If Owner’s TIN is pending at the time of application, the date the Owner applied for the TIN must be provided.             /            /            

For Additional Owners, identify each by name and provide all the above information for each (Type, Number, Expiration, etc.) or submit a separate Identification and Verification Form (22502).

Military Sales

Is the Applicant (or Owner, if other than Applicant) an active duty Service Member of the United States Armed Forces or a dependent family member of a Service Member? Yes No (If “Yes”, Notice to Military Service Members, form #22774, is required. Answer required only for individuals applying for new business.) Source of Funds

Type of new plan: Fixed Life Variable Life

For Fixed Life plan only: Will the Applicant use proceeds from the redemption, surrender, withdrawal, loan, or sale of an existing variable life insurance policy, variable annuity contract, mutual fund, or other securities product to pay premiums on the proposed life insurance policy? Yes No (Source of Funds Form 22692 required if answer is “Yes”)

3. How Well Known

How well do you know the Primary Insured? (Select one)

Approached by Primary Insured Casually, for             years Met on solicitation

Well, for             years Referral from NYL Agent Relative (relationship)            Self

If this sale is a result of a lead you received from New York Life, please provide the lead source. (Name of campaign)            

4. Purpose (Select all that apply)

Retirement Planning Income to Surviving Spouse and/or Children Executive Bonus Tax-Qualified Plan Purchase

College Funding Mortgage Protection Creditor Other             Gift to Child/Grandchild Estate Conservation Buy/Sell             Key Employee Split Dollar – Endorsement Non-Qualified Deferred Compensation

5. Policyowner Information (Complete only if Owner is an Individual)

Marital status: Married Single Divorced Separated Widowed

Number of Dependents: (including spouse)             Ages             Is Policyowner a homeowner? Yes No

Household Income: None $20,000 and below $20,001 – $50,000 $50,001 – $75,000 $75,001 – $100,000 $100,001 – $175,000 $175,001 – $250,000 $250,001 – $500,000 $500,001 and above

6. Requirements Processing

Is there a concurrent application related to this application? Yes No Policy number and details             Are you using requirements from a previous application? Yes No             

7. Additional Information

Please provide any information that is pertinent to the underwriting process that was not disclosed on the Application.

            AOL %             Do you want the additional amount on the AOL policy to be issued as a 5 year term rider? Yes No

Required to be completed for LWVUL

Managed Account #             Proposal ID             

8. Compensation

Are you requesting advance commissions? (If applicable) Yes No

For plans with Choice Compensation: (Select one) 1) FYC only 2) FYC + Trailers 3) FYC + Expense Allowance

9. Declaration (“I” refers to the Soliciting Agent)

I Declare that: a) the application was secured by me personally, and that I have no understanding or agreement with any other person or company, directly or indirectly, as to commissions or compensation on any policy or contract applied for, except as may be specified below; and b) I have not paid or allowed, and I agree that I will not hereafter pay or allow, either directly or indirectly, any compensation or commission other than below, or any rebate of premium in any manner whatsoever to the Applicant or Owner I acknowledge and represent. (1) I, or an interpreter as indicated on the application, read each question on the application (including any applicable health questionnaire), and explained the provisions and limitations of the coverage applied for to the Proposed Insured, Applicant (if not the Proposed Insured) and the Owner, in English, or, as indicated on the application, in another language understood by the Proposed Insured/Applicant/Owner as applicable, and I accurately recorded his/her responses; (2) If prepayment was collected, I gave the receipt and explained that coverage is provided only as stated in the Temporary Coverage Agreement, and that it is limited in amount and have promptly submitted the prepayment to the Company; (3) All information provided on this Report, or in response to Company inquiries about the application or the Proposed Insured, is true and correct to the best of my knowledge and belief; (4) I have used only Company approved sales material in connection with this application; and copies of all materials used have been left with the Applicant and that (5) I gave any other required form(s), including the information practices and privacy notices on or before the date the application was signed.

            Share % Code No. Print Last Name Signature (Soliciting Agent) Date

            Receive

Share % Code No. Print Last Name Signature (Optional) NB21 Alerts? Stamp Received “OFFICE”

            Receive Here Date Share % Code No. Print Last Name Signature (Optional) NB21 Alerts?

NAMES AND CONTACT INFORMATION OF FOUR FRIENDS AND RELATIVES

1.             3.             

2.             4.             

IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR ANNUITIES

Important considerations if you are contemplating replacing your existing policy or annuity contract

A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison of the costs and benefits of your existing policy or annuity contract and the proposed policy or annuity contract. One way to do this is to ask the company or producer that sold you your existing policy or annuity contract to provide you with information concerning your existing policy or annuity contract.

This may include an illustration of how your existing policy or annuity contract is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare policies or annuity contracts. You should discuss the following with your producer to determine whether replacement or financing your purchase makes sense:

Premiums Policy Values

• Are they affordable? • New policies usually take longer to build cash values and to pay dividends.

• Could they change?

Acquisition costs for the old policy may have been paid, you will incur

• You’re older—are premiums higher for the proposed new policy? costs for the new one.

• How long will you have to pay premiums on the new policy? • What surrender charges do the policies have?

On the old policy?

What expense and sales charges will you pay on the new policy?

Does the new policy provide more insurance coverage?

Insurability If you are keeping the old policy as well as the new policy

• If your health has changed since you bought your old policy, • How are premiums for both policies being paid? the new one could cost you more, or you could be turned down.

How will the premiums on your existing policy be affected?

• You may need a medical exam for a new policy.

Will a loan be deducted from death benefits?

• Claims on most new policies for up to the first two years can be denied based on inaccurate statements. • What values from the old policy are being used to pay premiums?

• Suicide limitations may begin anew on the new coverage.

If you are surrendering an annuity or interest sensitive life product Other issues to consider for all transactions

• Will you pay surrender charges on your old annuity contract? • What are the tax consequences of buying the new policy?

• What are the interest rate guarantees for the new annuity contract? • Is this a tax-free exchange? (See your tax advisor)

• Have you compared the contract charges or other policy expenses? • Is there a benefit from favorable “grandfathered” treatment of the old policy under the federal tax code?

Will the existing insurer be willing to modify the old policy?

How does the quality and financial stability of the new company compare with your existing company?

New York Life Insurance Company • 51 Madison Avenue • New York, NY 10010

New York Life Insurance and Annuity Corporation (A Delaware Corporation) • 51 Madison Avenue • New York, NY 10010

NYLIFE Insurance Company of Arizona (a subsidiary of New York Life) 4343 North Scottsdale Rd., Suite 220, Scottsdale, AZ 85251 • (not licensed in every state)

22190.100 CUSTOMER COPY

IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR ANNUITIES

This document must be signed by the Applicant and the Producer, and a copy left with the Applicant.

You are contemplating the purchase of a life insurance policy or annuity contract. In some cases the purchase may involve discontinuing or changing an existing policy or annuity contract. If so, a replacement is occurring. Financed purchases are also considered replacements.

A replacement occurs when a new policy or annuity contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing policy or annuity contract, or an existing policy or annuity contract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase.

A financed purchase occurs when the purchase of a new life insurance policy involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing policy, to pay all or part of any premium or payment due on the new policy. A financed purchase is a replacement.

You should carefully consider whether a replacement is in your best interest. You will pay acquisition costs and there may be surrender costs deducted from your policy or annuity contract. You may be able to make changes to your existing policy or annuity contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy and may reduce the amount paid upon the death of the insured.

We want you to understand the effects of replacement before you make your purchase decision and ask that you answer the following questions and consider the questions on the reverse side of this form.

1. Do you own any existing life insurance policies or annuity contracts? (If “Yes”, complete questions 2, 3 and 4 below. qyes qno

If “No”, do not answer questions 2, 3 and 4.)

2. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, qyes qno or otherwise terminating your existing policy or annuity contract?

3. Are you considering using funds from your existing policies or annuity contracts to pay premiums due on the new qyes qno policy or annuity contract?

4. Is the life insurance policy or annuity contract for which you are applying, to be the result of a 1035 exchange? qyes qno If you answered “Yes” to questions 2, 3, or 4, list each existing policy or annuity contract you are contemplating replacing. Also identify for each policy whether it will be replaced, used as a source of financing or replaced in conjunction with a 1035 exchange. (If additional space is required, complete another form.)

Name of Insurance Company             Policy or Annuity Contract #            

q?Replaced q?1035 Exchange

Name of Insured or Annuitant             q?Financed

Name of Insurance Company             Policy or Annuity Contract #            

q?Replaced q?1035 Exchange

Name of Insured or Annuitant             q?Financed

Name of Insurance Company             Policy or Annuity Contract #            

q?Replaced q?1035 Exchange

Name of Insured or Annuitant             q?Financed

Name of Insurance Company             Policy or Annuity Contract #            

q?Replaced q?1035 Exchange

Name of Insured or Annuitant             q?Financed

Make sure you know the facts. Contact your existing company or its producer for information about the old policy or annuity contract. At your request, the existing insurer must send you an in-force illustration, policy summary or available disclosure documents. Ask for and retain all sales material used by the producer in the sales presentation. Be sure that you are making an informed decision.

The existing policy(ies) or annuity contract(s) is/are being considered for replacement because             

I do not want this notice read aloud to me. (Applicant must initial only if they do not want the notice read aloud.)

I certify that the responses herein are, to the best of my knowledge, accurate:

Applicant’s Signature Applicant’s Name (Printed) Date

XX Stamp

Producer Acknowledgement: By reason of this transaction, is replacement involved? yes no Received

Producer’s Signature Producer’s Name (Printed) Date Here Date “OFFICE”

XX

22190.100 CUSTOMER COPY

IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR ANNUITIES

Important considerations if you are contemplating replacing your existing policy or annuity contract

A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison of the costs and benefits of your existing policy or annuity contract and the proposed policy or annuity contract. One way to do this is to ask the company or producer that sold you your existing policy or annuity contract to provide you with information concerning your existing policy or annuity contract.

This may include an illustration of how your existing policy or annuity contract is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare policies or annuity contracts. You should discuss the following with your producer to determine whether replacement or financing your purchase makes sense:

Premiums Policy Values

• Are they affordable? • New policies usually take longer to build cash values and to pay dividends.

• Could they change?

Acquisition costs for the old policy may have been paid, you will incur

• You’re older—are premiums higher for the proposed new policy? costs for the new one.

• How long will you have to pay premiums on the new policy? • What surrender charges do the policies have?

On the old policy?

What expense and sales charges will you pay on the new policy?

Does the new policy provide more insurance coverage?

Insurability If you are keeping the old policy as well as the new policy

• If your health has changed since you bought your old policy, • How are premiums for both policies being paid? the new one could cost you more, or you could be turned down.

How will the premiums on your existing policy be affected?

• You may need a medical exam for a new policy.

Will a loan be deducted from death benefits?

• Claims on most new policies for up to the first two years can be denied based on inaccurate statements. • What values from the old policy are being used to pay premiums?

• Suicide limitations may begin anew on the new coverage.

If you are surrendering an annuity or interest sensitive life product Other issues to consider for all transactions

• Will you pay surrender charges on your old annuity contract? • What are the tax consequences of buying the new policy?

• What are the interest rate guarantees for the new annuity contract? • Is this a tax-free exchange? (See your tax advisor)

• Have you compared the contract charges or other policy expenses? • Is there a benefit from favorable “grandfathered” treatment of the old policy under the federal tax code?

Will the existing insurer be willing to modify the old policy?

How does the quality and financial stability of the new company compare with your existing company?

New York Life Insurance Company • 51 Madison Avenue • New York, NY 10010

New York Life Insurance and Annuity Corporation (A Delaware Corporation) • 51 Madison Avenue • New York, NY 10010

NYLIFE Insurance Company of Arizona (a subsidiary of New York Life) 4343 North Scottsdale Rd., Suite 220, Scottsdale, AZ 85251 • (not licensed in every state)

IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR ANNUITIES

This document must be signed by the Applicant and the Producer, and a copy left with the Applicant.

You are contemplating the purchase of a life insurance policy or annuity contract. In some cases the purchase may involve discontinuing or changing an existing policy or annuity contract. If so, a replacement is occurring. Financed purchases are also considered replacements.

A replacement occurs when a new policy or annuity contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing policy or annuity contract, or an existing policy or annuity contract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase.

A financed purchase occurs when the purchase of a new life insurance policy involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing policy, to pay all or part of any premium or payment due on the new policy. A financed purchase is a replacement.

You should carefully consider whether a replacement is in your best interest. You will pay acquisition costs and there may be surrender costs deducted from your policy or annuity contract. You may be able to make changes to your existing policy or annuity contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy and may reduce the amount paid upon the death of the insured.

We want you to understand the effects of replacement before you make your purchase decision and ask that you answer the following questions and consider the questions on the reverse side of this form.

1. Do you own any existing life insurance policies or annuity contracts? (If “Yes”, complete questions 2, 3 and 4 below. qyes qno

If “No”, do not answer questions 2, 3 and 4.)

2. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, qyes qno or otherwise terminating your existing policy or annuity contract?

3. Are you considering using funds from your existing policies or annuity contracts to pay premiums due on the new qyes qno policy or annuity contract?

4. Is the life insurance policy or annuity contract for which you are applying, to be the result of a 1035 exchange? qyes qno If you answered “Yes” to questions 2, 3, or 4, list each existing policy or annuity contract you are contemplating replacing. Also identify for each policy whether it will be replaced, used as a source of financing or replaced in conjunction with a 1035 exchange. (If additional space is required, complete another form.)

Name of Insurance Company             Policy or Annuity Contract #            

q?Replaced q?1035 Exchange

Name of Insured or Annuitant             q?Financed

Name of Insurance Company             Policy or Annuity Contract #            

q?Replaced q?1035 Exchange

Name of Insured or Annuitant             q?Financed

Name of Insurance Company             Policy or Annuity Contract #            

q?Replaced q?1035 Exchange

Name of Insured or Annuitant             q?Financed

Name of Insurance Company             Policy or Annuity Contract #            

q?Replaced q?1035 Exchange

Name of Insured or Annuitant             q?Financed

Make sure you know the facts. Contact your existing company or its producer for information about the old policy or annuity contract. At your request, the existing insurer must send you an in-force illustration, policy summary or available disclosure documents. Ask for and retain all sales material used by the producer in the sales presentation. Be sure that you are making an informed decision.

The existing policy(ies) or annuity contract(s) is/are being considered for replacement because             

I do not want this notice read aloud to me. (Applicant must initial only if they do not want the notice read aloud.)

I certify that the responses herein are, to the best of my knowledge, accurate:

Applicant’s Signature Applicant’s Name (Printed) Date

XX Stamp

Producer Acknowledgement: By reason of this transaction, is replacement involved? yes no Received “OFFICE”

Producer’s Signature Producer’s Name (Printed) Date Here Date XX

22190.100

INDIVIDUAL LIFE INSURANCE APPLICATION (PART I) TO: NEW YORK LIFE INSURANCE COMPANY (NYLIC) 51 Madison Avenue, New York, NY 10010

NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION (NYLIAC) (A Delaware Corporation) 51 Madison Avenue, New York, NY 10010

NYLIFE INSURANCE COMPANY OF ARIZONA (NYLAZ) (Not Licensed in Every State) 4343 North Scottsdale Rd., Suite 220, Scottsdale, AZ 85251

Policy No.             New Application Paid Change Request Additional Offer Program Amend Application Attained Age Term Conversion Add Rider Exercising a rider: PPO SPO SPPO

Reinstatement Original Age Term Conversion Reinstate OPP GIR GIR Face Increase IER

A. Primary Insured

First Name Middle Name Last Name Suffix Male Date of Birth (mm/dd/yyyy) Female Residence: Street (P.O. Box Not Permitted) City State Country Zip Code

Social Security No. or Tax ID No. Exempt Applied for Driver’s License No. State None (Provide details in Section Q)

Country of Citizenship Country of Birth State of Birth How Long Living in the USA?

U.S. or             Since Birth or             Years             Months Immigration Visa or Work Authorization (If other than a US citizen) Expiration: Occupation Type Number Month Year Employer Name: Street City State Country Zip Code

If age 18 or over, has Primary Insured used tobacco, nicotine or any nicotine substitution product in any form in the last five years? Yes No If “Yes”, provide type             and date of last use (Month)             (Year)             

B. Contact Information

Contact Primary Insured at: (List both and check primary) Home Phone Number: (            )             Business Phone Number: (            )             Best Time to Call: Between             AM PM and             AM PM (Please indicate widest time interval) Time zone: EST CST MST PST AST HST E-mail Address:            Special Instructions, if any            

In which language and dialect(s) was the sales interview conducted? Language            Dialect             First Name Last Name Relationship to Primary Insured Who acted as interpreter? Agent Other:

If the Primary Insured requires special services for the hearing impaired, indicate the service required.             

C. Owner (if not Primary Insured )

For all ownership types, name, address, and tax identification information is required. UTMA/UGMA requires Custodian’s information to be provided.

Type: Individual Trust Corporation Partnership Charitable Organization UTMA/UGMA (Provide Custodian’s information below) Owner/Custodian First Name Middle Name Last Name Suffix Male Date of Birth (mm/dd/yyyy) Female Residence: Street (P.O. Box Not Permitted) City State Country Zip Code

Telephone Number E-mail Address Social Security No. or Tax ID No. Exempt Applied for

(            )

Relationship to Primary Insured Country of Citizenship

U.S. or             Immigration Visa or Work Authorization (If other than a US citizen) Expiration:

Type Number Month Year

Trust

Name of Trust             Date of Trust             State where Trust established             Name of Trustee(s)            Relationship of Trustee(s) to Primary Insured             Beneficiary(ies) of Trust             Relationship of Trust Beneficiary(ies) to Primary Insured             

Uniform Transfers to Minors (UTMA/UGMA) Minor’s Date of Birth (mm/dd/yyyy) Name of Minor: First Middle Last Suffix

UTMA/UGMA for the state of Minor’s Social Security No. or Tax ID No. Exempt Applied for

C. Owner (continued)

Successor Owner Primary Insured Relationship to Primary Insured First Name Middle Name Last Name Suffix

Multiple Owners (Unless otherwise specified in Section Q, ownership will be joint with right of survivorship.) Date of Birth (mm/dd/yyyy) First Name Middle Name Last Name Suffix

Residence: Street (P.O. Box Not Permitted) City State Country Zip Code

Telephone Number E-mail Address Social Security No. or Tax ID No. Exempt Applied for

(            )

Relationship to Primary Insured Country of Citizenship

U.S. or             

Immigration Visa or Work Authorization (If other than a US citizen) Expiration:

Type Number Month            Year            

D. Applicant (if not Primary Insured)

Same as Owner

If Primary Insured is under age 18 years, complete the following questions.

Amount of in-force insurance on parent(s) or guardian(s): $            None

Are all other children in the family insured or to be insured for an amount at least equal to that on the Primary Insured? Yes No (If “No”, provide details in Section Q)

First Name Middle Name Last Name Suffix Date of Birth (mm/dd/yyyy)

Social Security No. or Tax ID No. Exempt Applied for Relationship to Primary Insured

Residence: Street (P.O. Box Not Permitted) City State Country Zip Code

E. Payer (if not Primary Insured)

Same as Owner Applicant

First Name Middle Name Last Name Suffix Social Security No. or Tax ID No. Exempt Applied for Residence: Street (P.O. Box Not Permitted) City State Country Zip Code Relationship to Primary Insured Relationship to Owner (if other than Primary Insured) Date of Birth (mm/dd/yyyy)

F. Mode, Policy Date, Premium Financing, Qualified Plans, Premium Notices and Other Requests

(All modes not available on every plan or product)

For Check-O-Matic mode complete attached Check-O-Matic authorization form. For NYL-A-Plan, complete form 21237 and 21242. For Government Allotment, use form 16513.

Payment: Annual Semi-Annual Quarterly Monthly

Check-O-Matic Government Allotment NYLIFE Securities Single Sum

NYL-A-Plan #            List Bill #             MainStay #             Chosen Policy Date             /            /            Preliminary term to             /            /            (available on WL, MPWL and CWL only)

Policy Transfers/Premium Financing

1. Does the Proposed Insured, Applicant or Owner plan to transfer any right, title, or ownership interest in the policy being applied for to a third party, or has any of these parties ever transferred any rights, title or ownership in any life insurance policy to a third party? . Yes No

2. Is any part of the premium for this policy being financed by a third party, or has the Proposed Insured, Applicant or Owner been offered any inducement, fee or compensation, including “free life insurance,” as an inducement to purchase life insurance? . Yes No

3. Has the Proposed Insured, Applicant or Owner, within the past twelve months, authorized any third party to have a life settlement or viatical company review their personal medical status?. Yes No If “Yes” to #1, #2 or #3, provide details in Section Q.

Qualified Plans: 401(k) 401(a) 412(e)(3) Keogh 457 Profit Sharing Defined Benefit Pension Option             Other Requests: Reduced paid up at lapse Non-transfer Option Split Dollar: Endorsement Split Dollar

Premium Notices

Send Premium notice to Owner’s other US address:

Street             City             State             Zip Code             The Owner may designate a secondary addressee to receive notice of past due premium/potential lapse of coverage.

Name             Street             City             State             Zip Code            

G. Primary Insured’s Beneficiary

Same as Owner Family Protection Standard Beneficiary Designation (includes Additional Insured and Children)

Named Beneficiaries (indicate class as 1st/Primary, 2nd/Secondary, etc.) Per Stirpes (Can only be checked if all beneficiaries are individuals) Full Name Date of Birth Social Security No./ Relationship to Class (First, Middle, Last) (mm/dd/yyyy) Tax ID No. Primary Insured Share

            Address & Phone #             Same as Primary Insured             Address & Phone #             Same as Primary Insured             Address & Phone #             Same as Primary Insured             Address & Phone #             Same as Primary Insured             

Address & Phone #             Same as Primary Insured

Trust

Name of Trust             Date of Trust             State where Trust established             Name, Address & Phone # of Trustee(s)             Relationship of Trustee(s) to Primary Insured             

Beneficiary(ies) of Trust             Relationship of Trust Beneficiary(ies) to Primary Insured             

Uniform Transfers to Minors (UTMA/UGMA)

Name, Address & Phone # of Custodian             as custodian for

Name of Minor            UTMA/UGMA for the state of             

Minor’s Date of Birth (dd/mm/yyyy)             Minor’s Social Security Number             

H. Current Health and Payment Information

Has the Proposed Insured or anyone proposed for coverage on the policy:

1. Within the last 90 days, been recommended by a physician or other medical practitioner to undergo diagnostic procedures or tests for any symptoms, illnesses or conditions? . Yes No

2. Within the last 2 years, been unable to work or unable to attend school, or been disabled for one month or more?. Yes No

3. Within the last 2 years, been admitted to a hospital or other medical facility for more than 2 consecutive days? . Yes No If “Yes” to #1, #2 or #3, do not collect deposit premium and provide name and details in Section Q.

Total amount paid $             If amendment, amount previously paid $             

4. Complete the following questions for any Proposed Insureds actual age 24 months old or younger (except for children under CI Rider and Family Protection Plan):

(a) Was the child born prematurely (less than 37 weeks gestation)? . Yes No (b) Was the child’s birth weight less than 5 pounds (2.27 kilograms)?. Yes No (c) Has the child required hospitalization or been diagnosed with a birth injury, congenital disorder, deformity, heart murmur, developmental delay, intellectual disability, or accidental injury?. Yes No If “Yes” to #4a, 4b, or 4c, provide name and details, including the name and address of physician or health care provider in Section Q.

I. Coverage Information

NYLIC RIDERS DIVIDEND OPTION Whole Life WP OPP COM WP CPB LCTR            PI YCTR PI (Select one) Custom Whole Life ADB Scheduled Bill CI $             $             Pd Up Ad Premium Pay Years             $             $             # units             Modified Premium Whole Life DOT LCTR            OCI 1 YCTR/OCI Accum Unscheduled PPO $             $             Prem Face Amount $             or $             (Lump Sum) $             LCTR            OCI 2             Premium $             LBR Cash $             PPB $             $             Automatic Premium Loan

Survivorship Whole Life 2nd to Die 1st to Die OPP COM WP             (Select one) Face Amount $             DOT EPR LFD Scheduled Bill $             Pd Up Ad Automatic Premium Loan $             $             $             $             Accum             LTR             Unscheduled $             Prem (Lump Sum) $             $             $             Cash

Yearly Convertible Term WP CI YCTR PI LBR             (Select one) Face Amount $             ADB # units             $             PPO $             $             Accum $             YCTR/ OCI $             Prem $             $             Cash

Level Premium Convertible WP LCTR            PI LCTR            OCI 2 YCTR PI CI PPO (Select one) Term             Year ADB $             $             $             # units            $             Accum Guaranteed Level Premium $             LCTR            OCI 1             YCTR/ OCI ECPO             Prem Face Amount $             LBR $             $             (LCT 11-20 only) $             Cash

Family Protection WP (Insured 1) LBR (Select one) Face Amount $             WP (Insured 2) Accum (Insured 1)             Prem Face Amount $             Cash (Insured 2) One Year Non-Renewable (Select one) Term Accum Face Amount $             Prem Cash

            OPP COM             Face Amount $             Scheduled Bill WP $             $             $             Unscheduled (Lump Sum)            $             NYLAZ

            Face Amount $             $             $             

NYLIAC RIDERS

Universal Life MDW CI OCI 1 LPBR             IRC Sec. 7702 Option: CVAT GPT ADB # units             $             $            Face Amount $             $             OCI 2             Life Insurance Option: $             GIR

Level (1) Increasing (2)

Face Amount plus Adjusted Premium (3) $             Planned Premium $             LBR Initial Premium $             

Survivorship Universal Life FTD 10 YLTR EPR             IRC Sec. 7702 Option: CVAT GPT $             $             $             $            Face Amount $             Life Insurance Option:             Level (1) Increasing (2) Face Amount plus Adjusted Premium (3) Planned Premium $             Initial Premium $             

I. Coverage Information

NYLIAC RIDERS

Custom UL Guarantee MDW LBR ROP

Face Amount $            Maximum ROP Benefit Amount $             Life Insurance Option ROP Percentage             % Level             ROP Benefit Interest Rate             % IRC Sec. 7702 Option $             CVAT             Planned Premium $            Planned Premium Paying Period            Addt’l 1st Year Premium $            

Custom SUL Guarantee LBR FTD ROP

Face Amount $            $             Maximum ROP Benefit Amount $             Life Insurance Option ROP Percentage             % Level             EPR 10YLTR ROP Benefit Interest Rate             % IRC Sec. 7702 Option $             $             CVAT             Planned Premium $            Planned Premium Paying Period             $             Addt’l 1st Year Premium $            

Nautilus Advantage Universal Life MDW CI OCI 1 LPBR             IRC Sec. 7702 Option CVAT GPT ADB # units             $             $            Face Amount $            $             OCI 2 Life Insurance Option: $             GIR

Level(1) Increasing(2)

Face Amount plus Adjusted Premiums (3) $             Planned Premium $            LBR Initial Premium $            

Nautilus Advantage Survivorship FTD 10 YLTR EPR             Universal Life $             $             $             $            IRC Sec. 7702 Option CVAT GPT

Face Amount $            Life Insurance Option: Level(1) Increasing(2) Face Amount plus Adjusted Premiums (3) Planned Premium $            Initial Premium $            

Instant Legacy—SPUL Submit completed Simplified Medical Questionnaire—Part II

Single Premium $            Do not complete section P “Non-medical Health Questionnaire” for Instant Legacy.

Variable Universal Life Accumulator MDW ADB OCI 1 IRC Sec. 7702 Option: CVAT GPT $             $             Face Amount $            LER CI

Life Insurance Option: GIR # units             OCI 2 Level (1) Increasing (2) $             GMDB $             Face Amount plus Adjusted Premium (3)             WSP

            LBR GMAB             Planned Premium $            Initial Premium $            

213-500 5

NYLIAC RIDERS

Survivorship Variable Universal Life Accumulator 1st to Die GMDB (Younger Insured’s Age 100)             IRC Sec. 7702 Option: CVAT GPT FTD             $            Face Amount $             Life Insurance Option: $             LER

EPR GMAB Level (1) Increasing (2) $             Face Amount plus Adjusted Premium (3)             Planned Premium $             Initial Premium $             

Lifetime Wealth Variable Universal Life MDW ADB GMDB OCI 1 IRC Sec. 7702 Option: CVAT GPT LER CI GMAB $             Face Amount $             

$             # Units            PAIR*

Life Insurance Option: LBR WSP OCI 2 Level (1) Increasing (2) $             Face Amount plus Adjusted Premium (3) Planned Premium $             Initial Premium $             Investment Adviser None *The Pre-Approved Increase Rider (PAIR) is optional for Attained Age Term Conversion and must             a be selected if desired. The PAIR rider is automatically included on all new issues.

Asset Preserver Submit completed Asset Preserver Application Supplement Face Amount $             or Single Premium $             *Benefit Payment Option: $             Base Only Base Plus EOB            Inflation Option            *Not all Benefit Payment Options available in all states.

Legacy Creator—SPVUL LBR             Single Premium $             $             Submit completed Simplified Medical Questionnaire—Part II

Do not complete section P “Non-medical Health Questionnaire” for Legacy Creator. Executive Benefits LTR (CorpExec VUL only) CorpExec VUL             CEUL STR (CorpExec VUL, CEUL, CorpExec Accumulator) BOLI             OLP (CorpExec Accumulator Only) CorpExec Accumulator             $             $             IRC Sec. 7702 Option: CVAT GPT

Face Amount $             Premium Paid at Issue: $            Billing Frequency: Annual Semi-Annual Quarterly Single Life Insurance Option: Planned Premium in Year 1: $            Level (1) Increasing (2) Planned Premium in Years 2-10: Face Amount plus Adjusted Premium (3) (if applicable) Year 2: $            Year 5: $            Year 8: $            Year 3: $            Year 6: $            Year 9: $            Unisex Issue: Yes No Year 4: $            Year 7: $            Year 10: $            

            Face Amount $             or $             $             Planned Premium $             Initial Premium $             IRC Sec. 7702 Option CVAT             Planned Premium $            Planned Premium Paying Period            Addt’l 1st Year Premium $            

Alternate and Additional Policy Requests (Complete plan, face amount, rider(s), rider amount, and dividend option requests below. If changes to other sections are being requested, provide instructions below or in Section Q.) Alternate Additional Plan:            Face Amount: $             Rider:            Rider Amount: $             Amount Paid:            Dividend Option:            (Additional

Only) CWL Premium Pay Years:             

Instructions:            

213-500 6

J. Personal Information

1. In the last 5 years, has the Primary Insured or any other Proposed Insured(s)

(a) had their driver’s license suspended or revoked? . Yes No If “Yes”, indicate name or maiden name (if applicable) of person(s) applying for coverage and give details below including reason, driver’s license # (if other than previously stated), State of license, and month and year of occurrence.

Name Reason License # State Date (month/year)

(b) been declined for issue, reinstatement or renewal of any type of life or health insurance? . Yes No If “Yes”, indicate name or maiden name (if applicable) of person(s) applying for coverage, give company name (including New York Life), reason and date.

Name Company Reason Date (month/year)

2. a) In the last 10 years, has the Primary Insured or any other Proposed Insured(s) plead guilty to, or been convicted of, or been imprisoned for any felony or misdemeanor, or are there any such charges currently pending? . Yes No b) If “Yes” to a conviction, is the Primary Insured or any other Proposed Insured(s) currently on parole or probation as a result of such conviction? . Yes No (If “Yes” to 2a or 2b, indicate name or maiden name (if applicable) of person(s) applying for coverage, and give details below, including reason, State, County, month and year of occurrence.) Name Reason State County Date (month/year)

3. In the next 12 months does the Primary Insured or any Proposed Insured plan to travel or reside outside the U.S. or Canada? . Yes No If “Yes”, indicate name of the person(s) applying for coverage, purpose of travel (personal or business), the country, the date(s) of travel and the duration(s) of stay.

Name Purpose Country Date (month/year) Duration

4. In the last 12 months has the Primary Insured or any other Proposed Insured engaged in, or intend to engage in within the next

12 months, any of the following:. Yes No (a) motorcycle snowmobile and/or all terrain vehicle (ATV) riding? Check all that apply. If “Yes”, provide the following details: Insured’s Name             Annual mileage             Vehicle used for             Safety helmet used? Yes No Safety course completed? Yes No (b) or any of the following: If “Yes”, check all that apply and complete Form Series 7663.

SCUBA or skin diving auto racing motorcycle racing power boat racing snowmobile racing all terrain vehicle (ATV) racing or any other type of vehicle racing sky diving rock/mountain climbing helicopter skiing cave exploration hot air ballooning rodeo riding flying as civilian pilot flying as a military pilot ultralight or hang-gliding

K. Other Coverage (List each Proposed Insured and details of other coverage)

Insured’s Name None In Force Pending Company Amount Personal Business $

If “Pending” is checked off above, what is the total amount of pending coverage, excluding New York Life, that will be placed in all companies for each insured? $            Use Section Q for Additional Details.

L. Financial Information

Primary Insured Other Insured Owner if not Primary Insured Current Annual Earned Income Current Annual Unearned Income Current Net Worth

M. Business and Creditor Insurance

Question 1 must be completed for all Business and Creditor Insurance (except Buy/Sell). Complete Questions 2, 3 and 4, as applicable. If more space is needed, use Section Q, Additional Details.

1. Will an employer, including a partnership, be the owner and beneficiary of the insurance applied for on the life of an employee or partner? Yes No (“Employer” includes related parties, such as an affiliate of the business.) If “Yes”, the Proposed Insured must acknowledge the following statement by initialing the space provided below.

I, the Proposed Insured, acknowledge and agree that: (1) my employer intends to insure my life; (2) I have been notified of the amount of insurance applied for on my life; (3) my employer will be a beneficiary of any policy proceeds payable upon my death; and (4) coverage may continue after my employment terminates.

Proposed Insured’s initials here:             

Notice to Owner: If “Yes” is checked above, you may be subject to IRS record keeping and annual reporting requirements relating to employer-owned life insurance contracts. Please consult with your tax advisor.

2. (a) If BUY/SELL, what is the net income $             and market value $            of the business?

(b) Does insured(s) have ownership in the business? If “Yes”, list all owners and percent of ownership for each (for survivorship policy, list each insured and provide ownership percentage for each).             Yes No             (c) Are all owners being insured? Provide details and amounts.             Yes No             

3. (a) If KEY EMPLOYEE, provide reason why employee is key to the organization, and length of time employed.

(b) Are all Key Employees being insured? Provide details and amounts.            Yes No             

4. If CREDITOR COVERAGE, what is the loan amount $            , term             (years)            (months), and purpose?

Purpose             If creditor requires collateral assignment, include completed collateral assignment with application.

N. Term Conversion

Sections A, C, D, E, F, G and I of the application are also required for contractual conversions. For non-contractual conversions or changes, underwriting is required.

1. Policy Number             Term Policy Term Rider

These term coverages can be attained age converted (AATC): OCI DOT AD105 and after TL AD 85 and prior Conversion of Spouse Conversion of Child 1YT (Div. Opt.)

Amount to be Converted: Term Policy $             Term Rider $             

Amount Remaining In Force: Term Policy $             Term Rider $             (If no amount entered, remainder will be terminated) If there is an amount remaining in force that qualifies under the PTIS (Point in Scale) Program to be carried over to a term rider on the new base plan, are any of the following riders being applied for? New rider without underwriting (less than 5 years from original issue and meets minimum amount rules) PTIS rider without underwriting (5 years or more from original issue date or does not meet minimum amount

rules) PTIS rider without underwriting (less than 5 years from original issue date and meets amount rules) New rider with underwriting required (Provide details in Section Q) Is a reduction in rating being requested? . Yes No If Waiver of Premium or MDW is being applied for, does the Primary Insured have a disability which prevents him/her from being actively at work?

(If “Yes”, provide details and dates in Section Q.) . Yes No If you are applying for Waiver of Premium or MDW on the Primary Insured and the existing policy does not include this benefit, complete Sections J and P of this application.

2. Policy Number             Term Policy Term Rider

These term coverages can be attained age converted (AATC): OCI DOT AD105 and after TL AD 85 and prior Conversion of Spouse Conversion of Child 1YT (Div. Opt.)

Amount to be Converted: Term Policy $             Term Rider $             

Amount Remaining In Force: Term Policy $             Term Rider $             (If no amount entered, remainder will be terminated) If there is an amount remaining in force that qualifies under the PTIS (Point in Scale) Program to be carried over to a term rider on the new base plan, are any of the following riders being applied for? New rider without underwriting (less than 5 years from original issue and meets minimum amount rules) PTIS rider without underwriting (5 years or more from original issue date or does not meet minimum amount rules) PTIS rider without underwriting (less than 5 years from original issue date and meets amount rules) New rider with underwriting required (Provide details in Section Q) Is a reduction in rating being requested? . Yes No If Waiver of Premium or MDW is being applied for, does the Primary Insured have a disability which prevents him/her from being actively at work?

(If “Yes”, provide details and dates in Section Q.) . Yes No If you are applying for Waiver of Premium or MDW on the Primary Insured and the existing policy does not include this benefit, complete Sections J and P of this application.

For Attained Age Term Conversions the following apply:

There will be no insurance in effect on the new policy prior to the policy date given in the policy or policy date specified here             /            /            , and coverage on the new policy will not begin until the coverage being converted has been terminated.

I agree that any monies due from a Conversion of a NYLIC or NYLAZ policy to a NYLIC Life policy will be credited to the Dividend Option of the new life conversion policy. I agree that any monies due from a Conversion of a NYLIC or NYLAZ policy to a NYLIAC Life Policy will be credited to the Initial Premium, which will be increased to equal the credit applied to my NYLIAC policy when the credit is greater than the requested Initial Premium of the new life conversion policy.

SWL/SVUL/SUL policies pay a death benefit on the second death only, and no death benefits are payable on a first death.

The items in the Temporary Coverage Agreement and the Signature Section of this application apply even when a NYLAZ policy is being converted or when the new policy is issued by NYLIAC, a subsidiary of NYLIC.

O. Guaranteed Insurability Option Date (PPO and GIR)

Scheduled Option Date: Mo.             Day             Year            

Date of marriage birth adoption Mo.             Day             Year            Proof of event is required.

Do Not Complete if Any Other Type of Medical Examination Part II is Required.

P. Non-Medical Health Questionnaire

First Name Middle Name Last Name Height             ft.             in. Weight             lbs.

(For each additional insured, please use a separate Additional Insured Non-Medical Health Questionnaire)

1.In the last 5 years, has the Proposed Insured consulted his or her primary physician, or other member of the medical profession, or been seen at a medical facility? Yes No Name             Address             Phone number (            )             -            Date of last visit:             /            /            Reason for visit:             Treatment or medication provided: (Provide details, name and dosage)             

2.List all medications prescribed in the last 2 years: (Include reason, dosage and frequency)             

3. In the last ten (10) years, has the Proposed Insured been diagnosed, treated, tested positive for or been given medical advice by a member of the medical profession for: (If “Yes”, circle all conditions that apply) a. Elevated blood pressure, chest discomfort, heart disorder, angina, murmur or irregular pulse? . Yes No b. Elevated blood sugar or diabetes?. Yes No c. Asthma, shortness of breath, chronic bronchitis (COPD), emphysema, lung disorder or any type of sleep disorder?. Yes No d. Cancer, tumor, melanoma, leukemia, Hodgkins or any other lymphoma?. Yes No e. Multiple sclerosis; epilepsy, seizures; intellectual disability; memory loss or other neurological disorder? . Yes No f. Pancreatitis; hepatitis; cirrhosis, liver disorder, anemia or other blood disorder?. Yes No g. Stroke, transient ischemic attack (TIA) or other circulatory disorder? . Yes No h. Kidney disorder; protein or blood in the urine, urinary tract disorder or elevated PSA?. Yes No i. Colitis; blood in stool; intestinal polyps or other intestinal disorder? . Yes No j. Muscle weakness; bone or back disorder; arthritis; lupus or other connective tissue disorder? . Yes No k. Any psychiatric or mental health condition (include counseling or hospitalization)? . Yes No l. Drug or alcohol use, used cocaine or other controlled substances (other than as prescribed by a physician), or been counseled or hospitalized for drug or alcohol use?. Yes No

4. In the last ten (10) years, has the Proposed Insured been diagnosed by a member of the medical profession or tested positive for Human

Immunodeficiency Virus (AIDS virus) or Acquired Immune Deficiency Syndrome (AIDS)? . Yes No

5. In the last two (2) years, has the Proposed Insured been treated by a member of the medical profession for any of the following symptoms, for which a final medical professional diagnosis is not yet known: chest pain or pressure; blood in urine; rectal bleeding; blood in stool; loss of consciousness; recurrent shortness of breath; or cough, fever, or headache lasting five or more days? (If “Yes”, circle all that apply) . Yes No

6. In the last two (2) years, other than as already stated, has the Proposed Insured: a. Had any surgery or been recommended to have

surgery?. Yes No b. Had any diagnostic tests (excluding HIV tests) or been recommended to have any diagnostic test other than already stated?

(Such as but not limited to an X-ray, CT scan, stress test, MRI or ultrasound other than for pregnancy) . Yes No c. Been unable to work, unable to attend school or been disabled for 30 days or more?. Yes No

7. Among Proposed Insured’s natural parents, brothers or sisters, has anyone been diagnosed or treated by a member of the medical profession for angina, heart disorder, stroke, diabetes or cancer? (If “Yes”, provide the following details: relationship; medical condition; age at onset of illness; current age, if alive, or age at death. If cancer indicated, provide type or location.). Yes No 8. a. In the last 12 months, has the Proposed Insured had a change in weight greater than 10 pounds?. Yes No b. If “Yes”, please provide how many pounds lost             or how many pounds gained             and check off all that apply: Diet Exercise Surgery Pregnancy Unknown

9. Complete the following questions if the Proposed Insured is actual age 70 or over: a. Within the last 2 years, has the Proposed Insured been unable to participate in normal activities or been confined at home? . Yes No b. Does the Proposed Insured live in a facility that provides him or her with personal care?. Yes No c. Has the Proposed Insured been hospitalized or evaluated, counseled or treated by a member of the medical profession for memory problems or disorientation?. Yes No d. Within the last 2 years, has the Proposed Insured had a fall resulting in a fracture, or been bed-ridden for 2 weeks or more, or has the Proposed Insured required assistance in walking, eating, bathing, toileting, or dressing? (Circle all that apply). Yes No

Give full details (including addresses and phone numbers of doctors) for all questions answered “Yes” above. If more space is needed, please use Section Q.

Onset Recovery

Ques. No. Reason – Include diagnosis, treatment, medication, surgery and outcomes Doctors, Hospitals and Medical Facilities Info Mo. Year Mo. Year

213-500 9

Q. Additional Details

Please refer to each section letter when providing additional details and remarks.

Section

213-500 10

Complete only for coverage on Additional Insureds

Additional Insured (Completion of Additional Insured Non-Medical Health Questionnaire is required.)

First Name Middle Name Last Name Suffix Male Date of Birth (mm/dd/yyyy) Female Residence: Street (P.O. Box Not Permitted) City State Country Zip Code

Social Security No. or Tax ID No. Exempt Applied for Driver’s License No. State None (Provide details in Section Q) Relationship to Primary Insured

Country of Citizenship Country of Birth State of Birth How Long Living in the USA?

U.S. or             Since Birth or             Years            Months Immigration Visa or Work Authorization (If other than a US citizen) Expiration: Occupation Type Number Month Year Employer Name: Street City State Country Zip Code

If age 18 or over, has Additional Insured used tobacco, nicotine or any nicotine substitution product in any form in the last five years? Yes No

If “Yes”, provide type             and date of last use (Month)             (Year)             

If Additional Insured is under age 18 years, complete the following questions.

Amount of in-force insurance on parent(s) and guardian(s): $            None

Are all other children in the family insured or to be insured for an amount at least equal to that on the Additional Insured? Yes No (If “No”, provide details in Section Q)

Named Beneficiaries Owner Primary Insured Trust UTMA/UGMA (For Trust or UTMA/UGMA, provide details in Section Q) Per Stirpes Full Name Date of Birth Social Security No./ Relationship to Class (First, Middle, Last) (mm/dd/yyyy) Tax ID No. Additional Insured Share             Address & Phone #             Same as Primary Insured             Address & Phone #             Same as Primary Insured Contact Information

Same as for Primary Insured

Contact Additional Insured at: (List both and check primary) Home Phone Number: (            )             Business Phone Number: (            )             Best Time to Call: Between             AM PM and             AM PM (Please indicate widest time interval) Time zone: EST CST MST PST AST HST E-mail Address:             Special Instructions, if any             

In which language and dialect(s) was the sales interview conducted? Language            Dialect             First Name Last Name Relationship to Additional Insured Who acted as interpreter? Agent Other:

If the Additional Insured requires special services for the hearing impaired, indicate the service required.             

Children’s Insurance Information (CI and Family Protection plan)

If any child’s address and/or phone # is different than the Primary Insured, provide details in Section Q.

First Name Middle Name Last Name Date of Birth Relationship to Social Security Male

(mm/dd/yyyy) Primary Insured No.             Female Exempt Applied for First Name Middle Name Last Name Date of Birth Relationship to Social Security Male (mm/dd/yyyy) Primary Insured No.             Female Exempt Applied for First Name Middle Name Last Name Date of Birth Relationship to Social Security Male (mm/dd/yyyy) Primary Insured No.             Female Exempt Applied for

Named Beneficiaries Owner Primary Insured

Full Name Date of Birth Social Security No./ Relationship to Class (First, Middle, Last) (mm/dd/yyyy) Tax ID No. Child Insured Share             Address & Phone #             Same as Primary Insured             Address & Phone #             Same as Primary Insured

1. Has any child proposed for coverage, displayed any physical or mental impairment due to illness, injury or birth defect or is any child currently taking prescribed medication on a regular basis? (If “Yes”, provide details, including reason, dosage, and frequency in Section Q). Yes No

2. In the last 5 years, has any child proposed for coverage been hospitalized or been unable to attend school regularly? (If “Yes”, provide details in Section Q) Yes No

Do Not Complete if Any Other Type of Medical Examination Part II is Required.

Additional Insured Non-Medical Health Questionnaire

First Name Middle Name Last Name Height             ft.             in. Weight             lbs.

(For each additional insured, please use a separate Additional Insured Non-Medical Health Questionnaire)

1.In the last 5 years, has the Proposed Insured consulted his or her primary physician, or other member of the medical profession, or been seen at a medical facility? Yes No Name             Address             Phone number (            )             -            Date of last visit:             /            /            Reason for visit:             Treatment or medication provided: (Provide details, name and dosage)             

2.List all medications prescribed in the last 2 years: (Include reason, dosage and frequency)             

3. In the last ten (10) years, has the Proposed Insured been diagnosed, treated, tested positive for or been given medical advice by a member of the medical profession for: (If “Yes”, circle all conditions that apply) a. Elevated blood pressure, chest discomfort, heart disorder, angina, murmur or irregular pulse? . Yes No b. Elevated blood sugar or diabetes?. Yes No c. Asthma, shortness of breath, chronic bronchitis (COPD), emphysema, lung disorder or any type of sleep disorder?. Yes No d. Cancer, tumor, melanoma, leukemia, Hodgkins or any other lymphoma?. Yes No e. Multiple sclerosis; epilepsy, seizures; intellectual disability; memory loss or other neurological disorder? . Yes No f. Pancreatitis; hepatitis; cirrhosis, liver disorder, anemia or other blood disorder?. Yes No g. Stroke, transient ischemic attack (TIA) or other circulatory disorder? . Yes No h. Kidney disorder; protein or blood in the urine, urinary tract disorder or elevated PSA?. Yes No i. Colitis; blood in stool; intestinal polyps or other intestinal disorder? . Yes No j. Muscle weakness; bone or back disorder; arthritis; lupus or other connective tissue disorder? . Yes No k. Any psychiatric or mental health condition (include counseling or hospitalization)? . Yes No l. Drug or alcohol use, used cocaine or other controlled substances (other than as prescribed by a physician), or been counseled or hospitalized for drug or alcohol use?. Yes No

4. In the last ten (10) years, has the Proposed Insured been diagnosed by a member of the medical profession or tested positive for Human

Immunodeficiency Virus (AIDS virus) or Acquired Immune Deficiency Syndrome (AIDS)? . Yes No

5. In the last two (2) years, has the Proposed Insured been treated by a member of the medical profession for any of the following symptoms, for which a final medical professional diagnosis is not yet known: chest pain or pressure; blood in urine; rectal bleeding; blood in stool; loss of consciousness; recurrent shortness of breath; or cough, fever, or headache lasting five or more days? (If “Yes”, circle all that apply) . Yes No

6. In the last two (2) years, other than as already stated, has the Proposed Insured: a. Had any surgery or been recommended to have surgery?. Yes No b. Had any diagnostic tests (excluding HIV tests) or been recommended to have any diagnostic test other than already stated?

(Such as but not limited to an X-ray, CT scan, stress test, MRI or ultrasound other than for pregnancy) . Yes No c. Been unable to work, unable to attend school or been disabled for 30 days or more?. Yes No

7. Among Proposed Insured’s natural parents, brothers or sisters, has anyone been diagnosed or treated by a member of the medical profession for angina, heart disorder, stroke, diabetes or cancer? (If “Yes”, provide the following details: relationship; medical condition; age at onset of illness; current age, if alive, or age at death. If cancer indicated, provide type or location.). Yes No 8. a. In the last 12 months, has the Proposed Insured had a change in weight greater than 10 pounds?. Yes No b. If “Yes”, please provide how many pounds lost             or how many pounds gained             and check off all that apply: Diet Exercise Surgery Pregnancy Unknown

9. Complete the following questions if the Proposed Insured is actual age 70 or over: a. Within the last 2 years, has the Proposed Insured been unable to participate in normal activities or been confined at home? . Yes No b. Does the Proposed Insured live in a facility that provides him or her with personal care?. Yes No c. Has the Proposed Insured been hospitalized or evaluated, counseled or treated by a member of the medical profession for memory problems or disorientation?. Yes No d. Within the last 2 years, has the Proposed Insured had a fall resulting in a fracture, or been bed-ridden for 2 weeks or more, or has the Proposed Insured required assistance in walking, eating, bathing, toileting, or dressing? (Circle all that apply). Yes No

Give full details (including addresses and phone numbers of doctors) for all questions answered “Yes” above. If more space is needed, please use Section Q.

Onset Recovery

Ques. No. Reason – Include diagnosis, treatment, medication, surgery and outcomes Doctors, Hospitals and Medical Facilities Info Mo. Year Mo. Year

Check-O-Matic (C-O-M) – New Business Cases Only

1. New York Life Insurance Company, New York Life Insurance and Annuity Corporation or NYLIFE Insurance Company of Arizona, as indicated in this application, will direct the transfer of funds from the account you designate. This transfer will be used to pay premiums on the policy (policies) and/or monthly Option to Purchase Paid-up Additions (OPP) premiums. This transfer will be done each month on a regular schedule established by us. You will not receive premium notices while this arrangement is in effect.

2. This arrangement does not change the premium due dates specified in the policy and it does not extend any of the grace or late periods for paying these premiums. The policy or policies will lapse at the end of the grace or late period if the premium remains unpaid.

3. Any policy included under this arrangement is subject to our minimum and maximum premium and OPP premium rules.

4. The arrangement will apply to the policies listed below and will cover all future premiums and any current premiums that have not yet been paid.

Complete information below:

Primary Insured’s Name:            Policy Number             

Indicate Type:

Single Check-O-Matic Check-O-Matic OPP

Multiple Check-O-Matic Previous Case Reference Number or Policy Number            Add to Check-O-Matic Previous Case Reference Number or Policy Number            Concurrent Insured’s Name            Date of Birth:             /            /            

ELECTRONIC FUNDS TRANSFER (EFT)

Check here to pay your initial premium payment via EFT. This initial payment will be processed on or after the date the form is signed. PLEASE NOTE: One Time EFT payments are not available for Variable Products. To have your payment(s) withdrawn directly from your bank account, via an Electronic Funds Transfer (EFT), please provide the following information or attach a VOID check/deposit slip with the following information. Please Check One: Checking Account Savings Account

IMPORTANT: Please print all information clearly.

3rd Party Payer Information

A 3rd party payer is someone other than the designated Policyowner or insured of the policy. If payment is coming from a 3rd party, the payer will need to complete the information below. If this information is not provided, your request for the Check-O-Matic premium payment option cannot be processed.

Name:             Date of Birth:             First Name Middle Initial Last Name

Address (Street, City, State, and Zip Code REQUIRED. P.O. Box not acceptable):             

Relationship to the Policyowner:             Social Security Number/Tax ID Number             

Authorization Statement for Check-O-Matic (applies to Premium payments only)

I understand that I may discontinue this payment arrangement by notifying the Insurer. The Owner of each policy may discontinue it for his or her own policy. The arrangement ends on the day the Insurer receives the notice.

By initialing below I/We authorize New York Life Insurance Company or one of its subsidiaries to make monthly withdrawals from the account named above. I/We also authorize the Financial Institution named above to debit my/our account accordingly: Initials of Depositor(s) X             Is the Depositor the Policyowner? Yes No If “No”, Depositor is Primary Insured Applicant Payer (Check all that apply)

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Statement of Agreement

Those Persons Who Sign This Application Agree That:

1. All of the statements, which are part of the application, are correctly recorded, and are complete and true to the best of the knowledgeand belief of those persons who made them. Answers that are not true and complete may, subject to the policy’s Incontestability

Provision, invalidate coverage.

2. No agent or medical examiner has any right to accept risks, make or change contracts, or give up New York Life Insurance Company’s,

New York Life Insurance and Annuity Corporation’s or NYLIFE Insurance Company of Arizona’s rights or requirements.

3. “Cash Paid” with the application with respect to a new policy or additional benefit, provides a limited amount of temporary coveragefor up to 90 days, if the terms and conditions of the Temporary Coverage Agreement are met. Temporary coverage is not provided if apolicy or benefit is applied for under the terms of a conversion privilege or a guaranteed insurability option, or if reinstatement isapplied for. Further, a reinstatement will not take effect until (a) the Insurer approves the application, and (b) the sum required by the

Insurer with respect to the reinstatement application is paid during the lifetime of all persons to be covered under the reinstated policy.

4. The policy date is the date from which premiums are calculated and become due. The effective date is the date the policy is deliveredand the first premium is paid.

Unless temporary coverage is obtained, coverage does not begin until the effective date. If the policy

date is earlier than the effective date of coverage, the Policyowner pays a premium calculated beginning on that earlier policy datealthough coverage does not begin until the effective date.

At the time of application, or on or before the effective date, the Applicant or Policyowner can select a policy date. The policy datemay be chosen to correspond to the effective date, to obtain a lower premium rate based on a younger insurance age, because it ispreferable to pay premiums on that date or have policy values accrue as of that date, or for other reasons. If no Chosen Policy Date isselected, and if no temporary coverage is obtained, the date that the policy is issued will be the policy date. It is further agreed andunderstood that if the policy applied for is a universal life product, interest will not be credited on the policy until the premium isreceived by the service office.

5. By paying premiums on a basis more frequently than annually, that is monthly, quarterly, semi-annually, NYL-A-Plan, or by Check-O-

Matic, the total premium paid during one year’s time will be greater than if the premium were paid once each year, or annually. In otherwords, the cost of paying annualized periodic payments will be more than the cost of paying one annual premium. This applies to allproducts issued by New York Life Insurance Company and NYLIFE Insurance Company of Arizona.

6. WARNING: The arrangement of a sale, transfer or assignment of this policy, prior to or within a period of time specified by state lawafter the date the policy was issued, to a third party, such as a viatical settlement entity, a life settlement entity, other secondary marketprovider or premium financing entity, may violate the law of your state of residence. If there are any questions pertaining to thesematters please consult with your legal advisor.

Fraud Warnings:

FOR ARKANSAS: 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 fines and confinement in prison.

FOR DISTRICT OF COLUMBIA: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of

defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance

benefits if false information materially related to a claim was provided by the applicant.

Illustration

Do not complete this section if:

1. A signed illustration is not required by law; or 2. An illustration was signed and matches the policy applied for.

I, the Applicant, did not sign an illustration because:

An illustration was not shown or given to me.

An illustration was shown or given to me, but the policy applied for is different from the illustration.

An illustration was displayed to me on a screen. The displayed illustration matches the policy applied for, but no printed copy ofthe illustration was furnished. The illustration on the screen included the following personal and policy information:

Type of Policy

Proposed Insured

Initial Death Benefit

Rating/Class

Dividend Option

Age

Sex

I acknowledge that I did not sign an illustration for the reason stated above and I understand that an illustration matching the policy asissued will be provided for signature no later than at the time the policy is delivered.

CUSTOMER COPY

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Statement of Agreement

Those Persons Who Sign This Application Agree That:

1. All of the statements, which are part of the application, are correctly recorded, and are complete and true to the best of the knowledge and belief of those persons who made them. Answers that are not true and complete may, subject to the policy’s Incontestability Provision, invalidate coverage.

2. No agent or medical examiner has any right to accept risks, make or change contracts, or give up New York Life Insurance Company’s, New York Life Insurance and Annuity Corporation’s or NYLIFE Insurance Company of Arizona’s rights or requirements.

3. “Cash Paid” with the application with respect to a new policy or additional benefit, provides a limited amount of temporary coverage for up to 90 days, if the terms and conditions of the Temporary Coverage Agreement are met. Temporary coverage is not provided if a policy or benefit is applied for under the terms of a conversion privilege or a guaranteed insurability option, or if reinstatement is applied for. Further, a reinstatement will not take effect until (a) the Insurer approves the application, and (b) the sum required by the Insurer with respect to the reinstatement application is paid during the lifetime of all persons to be covered under the reinstated policy.

4. The policy date is the date from which premiums are calculated and become due. The effective date is the date the policy is delivered and the first premium is paid. Unless temporary coverage is obtained, coverage does not begin until the effective date. If the policy date is earlier than the effective date of coverage, the Policyowner pays a premium calculated beginning on that earlier policy date although coverage does not begin until the effective date.

At the time of application, or on or before the effective date, the Applicant or Policyowner can select a policy date. The policy date may be chosen to correspond to the effective date, to obtain a lower premium rate based on a younger insurance age, because it is preferable to pay premiums on that date or have policy values accrue as of that date, or for other reasons. If no Chosen Policy Date is selected, and if no temporary coverage is obtained, the date that the policy is issued will be the policy date. It is further agreed and understood that if the policy applied for is a universal life product, interest will not be credited on the policy until the premium is received by the service office.

5. By paying premiums on a basis more frequently than annually, that is monthly, quarterly, semi-annually, NYL-A-Plan, or by Check-O-Matic, the total premium paid during one year’s time will be greater than if the premium were paid once each year, or annually. In other words, the cost of paying annualized periodic payments will be more than the cost of paying one annual premium. This applies to all products issued by New York Life Insurance Company and NYLIFE Insurance Company of Arizona.

6. WARNING: The arrangement of a sale, transfer or assignment of this policy, prior to or within a period of time specified by state law after the date the policy was issued, to a third party, such as a viatical settlement entity, a life settlement entity, other secondary market provider or premium financing entity, may violate the law of your state of residence. If there are any questions pertaining to these matters please consult with your legal advisor.

Fraud Warnings:

FOR ARKANSAS: 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 fines and confinement in prison. FOR DISTRICT OF COLUMBIA: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Illustration

Do not complete this section if:

1. A signed illustration is not required by law; or 2. An illustration was signed and matches the policy applied for.

I, the Applicant, did not sign an illustration because:

An illustration was not shown or given to me.

An illustration was shown or given to me, but the policy applied for is different from the illustration.

An illustration was displayed to me on a screen. The displayed illustration matches the policy applied for, but no printed copy of the illustration was furnished. The illustration on the screen included the following personal and policy information:

Type of Policy             Proposed Insured             Initial Death Benefit             Rating/Class             Dividend Option             Age             Sex             

I acknowledge that I did not sign an illustration for the reason stated above and I understand that an illustration matching the policy as issued will be provided for signature no later than at the time the policy is delivered.

Tax Certification

Under penalties of perjury, I (as the Owner named in Section A or C) certify that: (1) the Social Security or Employer ID Number shown in this application is my correct taxpayer identification number, or I am awaiting a number to be issued to me (noted as “applied for” in Section A or C) AND (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding; or (b) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends; or (c) the IRS has notified me that I am no longer subject to backup withholding (Cross out item 2 if the IRS has notified you that you are subject to backup withholding.) and (3) I am a U.S. person (including a U.S. resident alien).

ACKNOWLEDGEMENT

I, the Proposed Insured, have been given a copy of “Information Practices Related to Underwriting Your Application” which tells how New York Life Insurance Company, New York Life Insurance and Annuity Corporation and NYLIFE Insurance Company of Arizona obtain and use data about me. It includes the notice required by the State and Federal Fair Credit Reporting Acts and a description of MIB, Inc. (Medical Information Bureau). I know that my application cannot be processed if I do not sign the Authorization below.

AUTHORIZATION

In this Authorization, “I”, “my” and “me” mean the Proposed Insured, “the Insurer” means New York Life Insurance Company, New York Life Insurance and Annuity Corporation, and NYLIFE Insurance Company of Arizona and their respective agents, employees, and representatives. In order to see if (and on what basis) I qualify for the insurance applied for or any other insurance offered by any of the insurers identified above, I authorize the following: MEDICAL INFORMATION: Physicians or practitioners; hospitals; medical or medically related facilities; pharmacies, pharmacy benefit managers or medical information retrieval services; laboratories; insurance companies; or MIB, Inc. may give to the Insurer (or any consumer reporting agency acting on its behalf) and to any of its reinsurers, at my request, copies of the record or other data that they may have about my physical and mental health, and my prescription drug history. This includes all protected health information and any health information I have previously requested be withheld from further disclosure, and including my history, their findings, diagnoses and treatment. Mental health professionals may provide their records of my diagnosis, functional status, treatment plan, symptoms, prognosis, progress to date, medication prescription and monitoring, and clinical test results. OTHER UNDERWRITING INFORMATION MIB, Inc., other insurance companies and consumer reporting agencies may give to the Insurer and to any of its reinsurers data about: my driving record; any criminal activity or association; hazardous sport or aviation activity; use of alcohol or drugs; any claim of eligibility for disability income benefits; other applications for life insurance; and other policies of life insurance.

EXAMINATIONS AND TESTS The Insurer may obtain physical examinations or medical tests deemed necessary to underwrite my application. These tests (where permitted by law) may include, but are not limited to, electrocardiograms, chest x-rays and tests of blood and urine to determine, among other things, exposure to causative agents of disease (for example, exposure to the AIDS virus) and the presence of drugs. However, a separate notification/authorization form will be provided with respect to testing for the AIDS virus.

INVESTIGATIVE CONSUMER REPORT The Insurer may obtain an investigative consumer report and may give the consumer reporting agency information concerning the amount and type of my coverage and my use, if any, of tobacco. The report may add to or confirm the types of data mentioned above. It may also contain data about: my identity; age; residence; marital status; past and present jobs (including work duties); economic conditions; driving record; personal and business reputation in the community; and mode of living; but will not include any information relating directly or indirectly to sexual orientation.

IDENTIFICATION To obtain the data described above, the Insurer may give my name, address, and date and place of birth to the above persons or organization.

RELEASE OF INFORMATION TO OTHERS The Insurer may give data about me that affects my insurability to: its subsidiaries; its affiliates; its parent company; its agents and their staffs; its reinsurers; and the Insurer and its reinsurers may give such data, including a brief report of my protected health information and data about any life insurance policy(ies) Insurer issues on me, to MIB, Inc. However, this will not be done in connection with information relating to testing for the AIDS virus.

I also authorize the release of these same types of data about any of my children who are to be insured. This Authorization may be used for a period of 24 months from the date signed below unless sooner

revoked. I may revoke this Authorization at anytime by notifying the Insurer in writing. This revocation will not be effective to the extent the Insurer or any other person already has disclosed or collected information or taken other action in reliance on it, or to the extent the Insurer has a legal right to contest a claim under an insurance policy or to contest the policy itself. The information the Insurer obtains through this Authorization may become subject to further disclosure. For example, the Insurer may be required to provide it to an insurance regulatory or other government agency. In this case, the information may no longer be protected by the rules governing this Authorization. A photocopy of this Authorization and request form shall be as valid as the original. I know that I may request a copy of this Authorization. (Please provide a copy to me.             initial if requested).

The Internal Revenue Service Does Not Require Your Consent To Any

Provision Of This Document Other Than The Certifications Required To Avoid Backup Withholding. Signatures

By signing below, I/We understand that I/We acknowledge and agree to all of the statements and representations made in this application, including sections entitled Business and Creditor Insurance (if applicable), Statement of Agreement, Illustration (if applicable), Check-O-Matic (if applicable), Tax Certification, Acknowledgement and Authorization. I/We accept and adopt as true all statements made by the Proposed Insured(s) in this application.

X             Signed at             On             

Signature of the Primary Insured (Parent or Guardian if under 14 years 6 months) (City, State) (mm/dd/yyyy)

X             

Signature of the Owner if Other than the Primary Insured Title if signed on behalf of Corporation, Trust, etc.

X             X             

Signature of Applicant if Other than Primary Insured or Owner Signature of Other Insured

X             X             

Signature of Other Insured Signature of Other Insured

X             

Other Required Signature

I Certify I have truly and accurately recorded all answers given to me.

X             X             Signature of Agent/Witness Countersigned by Licensed Resident Agent (if required) X             Signature of Agent/Witness Countersigned Code #

213-500

NEW YORK LIFE INSURANCE COMPANY

NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION (A Delaware Corporation) NYLIFE INSURANCE COMPANY OF ARIZONA (Not Licensed in Every State)

NOTICE CONCERNING CIVIL UNION LAWS

Illinois Religious Freedom Protection and Civil Union Act

The Illinois Department of Insurance has directed that Illinois residents receive notification regarding the benefits and protections under the Illinois Religious Freedom Protection and Civil Union Act, which became effective on June 1, 2011.

The Act creates a legal relationship between two persons of the same or opposite sex who form a Civil Union under the law. Under the Act, a Party to a Civil Union is extended policy benefits and protections identical to those currently granted to a party to a marriage.

Delaware Civil Union and Equality Act

The Delaware Department of Insurance has directed that Delaware residents receive notification regarding the benefits and protections under the Delaware Civil Union and Equality Act of 2011, which became effective on January 1, 2012.

The Act creates a legal relationship between two persons of the same sex who form a Civil Union under the law. Under the Act, a Party to a Civil Union is (i) extended identical benefits, rights and protections, and (ii) subject to the same responsibilities, obligations and duties under the policy as currently granted to, or imposed upon, married persons under Delaware law.

If you require additional information about this notice, please contact your agent/registered representative or Service Center.

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NEW YORK LIFE INSURANCE COMPANY (NYLIC)

NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION (NYLIAC) NYLIFE INSURANCE COMPANY OF ARIZONA (NYLAZ)

RECEIPT AND TEMPORARY COVERAGE AGREEMENT (the “Agreement”)

(limited in amount)

Received from            on            the sum of $            . This amount is specified in Section H. of the application Part I bearing the same date and number as this receipt.

            Agent’s Signature

In this Agreement, the words “we”, “us”, and “our” mean the Insurer C. Question 1, 2 and 3 of Section H of the Application Part I must checked above and the words “you” and “your” mean the Applicant. be answered “No” for all persons proposed for coverage; We acknowledge receipt of your application for a life insurance policy, D. The Application Part I is signed by all required parties, including and of your payment to us in the amount noted above. Any check the Applicant, the Proposed Insured(s) (if other than the tendered must be made payable to New York Life Insurance Company Applicant), and Agent. or New York Life Insurance and Annuity Corporation or NYLIFE 2.No Coverage Provided: Insurance Company of Arizona, as shown above. Any check received will be subject to collection. Do not make any check payable to the There is no coverage provided under this Agreement: Agent and do not leave the Payee section of the check blank. This A. For suicide or intentionally self-inflicted injury of any of the Agreement is not transferable. proposed insureds, while sane or insane; If the application modifies a previous application and a payment was B. For any Spouse’s Paid-Up Insurance Purchase Option attached made in connection with the previous application, this receipt replaces to or included in the policy being applied for; and cancels any receipt which was previously given for that payment.

C. For a policy or benefit that is applied for under the terms of a We shall have no liability on account of the previous receipt or any contractual conversion privilege or guaranteed insurability temporary coverage provided under it. Our liability on account of any payment made with this application shall be as provided under this option. If that policy or benefit does not require our approval to receipt and its Temporary Coverage Agreement below. put it in force, it will take effect as soon as the requirements of Subject to the conditions set forth below, the above payment provides that privilege or option have been met; a limited amount of temporary life insurance coverage on the Proposed D. If reinstatement of a policy is being applied for; Insured from the date coverage begins, as defined below, to the

date E. Where question 1, 2 or 3 of Section H of the Application Part I coverage terminates, as defined below. If question 1, 2 or 3 of are answered “Yes” or are left blank, or are answered falsely;

Section H of the application Part I are answered “Yes” or are left blank, no money may be paid with the application whether to us F. If we are prohibited by any state or federal law, regulation or order from doing business with or participating in a transaction or to the Agent. In this case, no coverage will be provided under this involving any person identified as a Proposed Insured, Owner, Agreement. However, the application should still be submitted to us for evaluation WITHOUT PAYMENT. Applicant, Payer or Beneficiary in your application for a life insurance policy.

In determining whether to issue the policy that you have applied for, if all the conditions for coverage in Section 1 below have been met, 3.Amount and Period of Coverage: we will not consider information concerning changes in the health of any person proposed for coverage, where such change occurs after the A. Maximum Amount of Coverage: effective date of this Agreement and while this Agreement is in effect. The following amounts will apply depending on the policy applied for:

1.Coverage Provided:

Except as specifically stated otherwise in this Agreement, temporary (1) All Policies except Survivorship Policies. While this life insurance will be subject to all terms of the policy applied for. Agreement is in effect, we will provide coverage having the While this Agreement is in effect, coverage is provided under this same benefits and subject to the same terms as the policy Agreement only if the following requirements are fully met. (If these applied for had it become effective. However, the aggregate requirements are not fully met, any cash payment made will be coverage on account of all the temporary coverage for all refunded to the Applicant at the address given in the Application Insurers listed above, under this and any other receipt, on the Part I.): A. Submission of the application Part I with Sections A-I completed, person proposed for coverage in the application for all benefits (including Accidental Death Benefits and any other with all statements complete and true to the best of the benefits) shall in no event exceed $1,000,000 in total. Such knowledge and belief of the persons who made them; B. Collection of your payment submitted with your application, liability shall be further limited for any disability waiver of provided any check submitted is honored for payment when premium benefit so that the amount that may be waived does presented; not exceed $300 per month.

21620.100 CUSTOMER COPY Continued on reverse side

(2) Survivorship Policies. Survivorship Policies are policies being applied for. For policies that require a single premium under which the base policy death benefit is payable only payment, the sum paid in exchange for this Agreement must when two Proposed Insureds have died. The temporary be the full single premium payment for the face amount of coverage will provide the same benefits as the policy applied insurance and any riders being applied for; and for. It will also be subject to the same provisions, conditions, (2)All of the requirements in Section 1 of this Agreement have exceptions, limitations and reductions that would apply been met. under the policy had it become effective. However, the C. Date Agreement Terminates: temporary coverage will provide the lesser of: This Agreement and the coverage provided under it will (i) The amount of the life insurance proceeds applied for terminate on the earliest of the following dates: in the applications. This includes Accidental Death (1)90 days after the date this Agreement becomes effective; Benefits and other benefits, if applicable; or (2)The date of our notice to the Applicant(s) that the application (ii)$2,000,000 in total for all insurers listed above. has been declined; This benefit will be paid to the designated beneficiary if the (3)The date of the Applicant(s) written request for a full refund Proposed Insureds die while the temporary coverage is in effect. of the payment, in which event all coverage will be void from No benefits will be payable under this Agreement upon the death the start; of only one of the Proposed Insureds. However, we will pay (4)The date the policy is put in force, at which point all coverage benefits under an applied for rider that is to be attached to the shall be provided by the policy. policy, if such rider would pay benefits upon the death of that

4.Refund of Payment:

Proposed Insured. If one of the Proposed Insureds dies while this coverage is in effect and the other is found to be insurable, we If temporary life insurance is not payable under this Agreement will issue the policy. Such liability shall be further limited for any (except for the reason that the policy has been put in force), we will waiver of premium benefits so that the amount that may be refund your payment made with respect to the policy. waived does not exceed $300 per month. The total benefit limit If temporary life insurance becomes payable under this Agreement, applies to all insurance applied for on all persons proposed for the payment received will be applied as the first premium for the any coverage in the applications and any other Temporary life insurance applied for. We will refund an appropriate part of your Coverage Agreement. payment made with respect to the policy if our liability under this B. Date Agreement Begins: Agreement is, pursuant to Section 3(A), less than it would have been under the policy applied for.

This Agreement and the coverage provided under it will begin on the date the Application Part I is signed by all required 5.Limitation of Authority: parties, provided: No Agent or medical examiner has any right to accept any risk, make (1)The sum paid in exchange for this Agreement is enough to or change contracts, give up any of our rights or requirements, or provide at least one month’s coverage for the face amount of change the provisions of this Agreement. insurance and one month’s coverage for all riders that are

21620.100 CUSTOMER COPY

NEW YORK LIFE INSURANCE COMPANY (NYLIC)

NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION (NYLIAC) NYLIFE INSURANCE COMPANY OF ARIZONA (NYLAZ)

RECEIPT AND TEMPORARY COVERAGE AGREEMENT (the “Agreement”)

(limited in amount)

Received from            on            the sum of $            . This amount is specified in Section H. of the application Part I bearing the same date and number as this receipt.

            Agent’s Signature

In this Agreement, the words “we”, “us”, and “our” mean the Insurer C. Question 1, 2 and 3 of Section H of the Application Part I must checked above and the words “you” and “your” mean the Applicant. be answered “No” for all persons proposed for coverage; We acknowledge receipt of your application for a life insurance policy, D. The Application Part I is signed by all required parties, including and of your payment to us in the amount noted above. Any check the Applicant, the Proposed Insured(s) (if other than the tendered must be made payable to New York Life Insurance Company Applicant), and Agent. or New York Life Insurance and Annuity Corporation or NYLIFE 2.No Coverage Provided: Insurance Company of Arizona, as shown above. Any check received will be subject to collection. Do not make any check payable to the There is no coverage provided under this Agreement: Agent and do not leave the Payee section of the check blank. This A. For suicide or intentionally self-inflicted injury of any of the Agreement is not transferable. proposed insureds, while sane or insane; If the application modifies a previous application and a payment was B. For any Spouse’s Paid-Up Insurance Purchase Option attached made in connection with the previous application, this receipt replaces to or included in the policy being applied for; and cancels any receipt which was previously given for that payment.

C. For a policy or benefit that is applied for under the terms of a We shall have no liability on account of the previous receipt or any contractual conversion privilege or guaranteed insurability temporary coverage provided under it. Our liability on account of any payment made with this application shall be as provided under this option. If that policy or benefit does not require our approval to receipt and its Temporary Coverage Agreement below. put it in force, it will take effect as soon as the requirements of Subject to the conditions set forth below, the above payment provides that privilege or option have been met; a limited amount of temporary life insurance coverage on the Proposed D. If reinstatement of a policy is being applied for; Insured from the date coverage begins, as defined below, to the

date E. Where question 1, 2 or 3 of Section H of the Application Part I coverage terminates, as defined below. If question 1, 2 or 3 of are answered “Yes” or are left blank, or are answered falsely;

Section H of the application Part I are answered “Yes” or are left blank, no money may be paid with the application whether to us F. If we are prohibited by any state or federal law, regulation or order from doing business with or participating in a transaction or to the Agent. In this case, no coverage will be provided under this involving any person identified as a Proposed Insured, Owner, Agreement. However, the application should still be submitted to us for evaluation WITHOUT PAYMENT. Applicant, Payer or Beneficiary in your application for a life insurance policy.

In determining whether to issue the policy that you have applied for, if all the conditions for coverage in Section 1 below have been met, 3.Amount and Period of Coverage: we will not consider information concerning changes in the health of any person proposed for coverage, where such change occurs after the A. Maximum Amount of Coverage: effective date of this Agreement and while this Agreement is in effect. The following amounts will apply depending on the policy applied for:

1.Coverage Provided:

Except as specifically stated otherwise in this Agreement, temporary (1) All Policies except Survivorship Policies. While this life insurance will be subject to all terms of the policy applied for. Agreement is in effect, we will provide coverage having the While this Agreement is in effect, coverage is provided under this same benefits and subject to the same terms as the policy Agreement only if the following requirements are fully met. (If these applied for had it become effective. However, the aggregate requirements are not fully met, any cash payment made will be coverage on account of all the temporary coverage for all refunded to the Applicant at the address given in the Application Insurers listed above, under this and any other receipt, on the Part I.): A. Submission of the application Part I with Sections A-I completed, person proposed for coverage in the application for all benefits (including Accidental Death Benefits and any other with all statements complete and true to the best of the benefits) shall in no event exceed $1,000,000 in total. Such knowledge and belief of the persons who made them; B. Collection of your payment submitted with your application, liability shall be further limited for any disability waiver of provided any check submitted is honored for payment when premium benefit so that the amount that may be waived does presented; not exceed $300 per month.

21620.100 Continued on reverse side

(2) Survivorship Policies. Survivorship Policies are policies being applied for. For policies that require a single premium under which the base policy death benefit is payable only payment, the sum paid in exchange for this Agreement must when two Proposed Insureds have died. The temporary be the full single premium payment for the face amount of coverage will provide the same benefits as the policy applied insurance and any riders being applied for; and for. It will also be subject to the same provisions, conditions, (2)All of the requirements in Section 1 of this Agreement have exceptions, limitations and reductions that would apply been met. under the policy had it become effective. However, the C. Date Agreement Terminates: temporary coverage will provide the lesser of: This Agreement and the coverage provided under it will (i) The amount of the life insurance proceeds applied for terminate on the earliest of the following dates: in the applications. This includes Accidental Death (1)90 days after the date this Agreement becomes effective; Benefits and other benefits, if applicable; or (2)The date of our notice to the Applicant(s) that the application (ii)$2,000,000 in total for all insurers listed above. has been declined; This benefit will be paid to the designated beneficiary if the (3)The date of the Applicant(s) written request for a full refund Proposed Insureds die while the temporary coverage is in effect. of the payment, in which event all coverage will be void from No benefits will be payable under this Agreement upon the death the start; of only one of the Proposed Insureds. However, we will pay (4)The date the policy is put in force, at which point all coverage benefits under an applied for rider that is to be attached to the shall be provided by the policy. policy, if such rider would pay benefits upon the death of that

4.Refund of Payment:

Proposed Insured. If one of the Proposed Insureds dies while this coverage is in effect and the other is found to be insurable, we If temporary life insurance is not payable under this Agreement will issue the policy. Such liability shall be further limited for any (except for the reason that the policy has been put in force), we will waiver of premium benefits so that the amount that may be refund your payment made with respect to the policy. waived does not exceed $300 per month. The total benefit limit If temporary life insurance becomes payable under this Agreement, applies to all insurance applied for on all persons proposed for the payment received will be applied as the first premium for the any coverage in the applications and any other Temporary life insurance applied for. We will refund an appropriate part of your Coverage Agreement. payment made with respect to the policy if our liability under this B. Date Agreement Begins: Agreement is, pursuant to Section 3(A), less than it would have been under the policy applied for.

This Agreement and the coverage provided under it will begin on the date the Application Part I is signed by all required 5.Limitation of Authority: parties, provided: No Agent or medical examiner has any right to accept any risk, make (1)The sum paid in exchange for this Agreement is enough to or change contracts, give up any of our rights or requirements, or provide at least one month’s coverage for the face amount of change the provisions of this Agreement. insurance and one month’s coverage for all riders that are