Dated at __________________________
on __________________________,
______________________
________________________________________
______________________________________
Signature of Owner
Witness (Agent)
NEW YORK LIFE INSURANCE COMPANY
NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION (A Delaware Corporation)
51 Madison Avenue, New York, New York 10010 NYLIFE INSURANCE COMPANY OF ARIZONA
(Not Licensed in All States)
4343 North Scottsdale Road, Suite 220, Scottsdale, AZ 85251
20802 (05/13)
Application Corrections –In the event of an error on the application, the Applicant must initial all application corrections.
Fully completed Application, including Agent Statement, required for the following:(1) New Application, and (2) Insurance Exchange Rider (IER) This application should not be used to convert SEGLI/VGLI/FEGLI.
GENERAL REQUIREMENTS FOR VARIOUS TYPES OF REQUESTED ACTIONS
APPLICATION INSTRUCTIONS
Action Requested
Amending Previous Application (Policy not delivered)
Entry in Heading Check “Amend Application” box at the top of the application and insert Policy Number, if known.
Section Requiring an Answer Complete Section A and all fields being amended. Applicant cannot be amended. If premium is being taken, complete Section H and include the Temporary Coverage Agreement form.
Additional Information Additional requirements may be requested for an increase in risk. See Agents’ Service and Underwriting Manual (on Agency Portal). Adding on riders and increase in
face amount (for UL, Target Life or VUL) on any policies issued after 1/85. Also, for increase in face amount for Family Protection plan
Insert Policy No. Sections A, B, C, D, F, G, H, I, J, and L of the Part I. (Sections H, J, and L not required for Family Protection plan.) Also complete (except for FPT face increase) evidence of insurability per age/amount rules. Agent Statement required. For Family Protection face amount increase on 2nd Insured, complete Section A on PI1, complete Additional Insureds section on PI2 and Sections C, D, and I as required.
No cash may be taken on a Family Protection plan face amount increase. If adding OCI or CI and there is WP on the policy, then evidence of insurability on Primary Insured is needed. See Agents’ Service and Underwriting Manual. Signaturesof the
Policyowner/Owners and the Insured whose face amount is being increased are required under the consent to life insurance rules.
PPO (Policy Purchase Option), GIR (Guaranteed Insurability Rider), SPO (Survivor Purchase Option), or SPPO (Spouse’s Paid up Insurance Purchase Option)
GIR Option to increase face amount of UL, Target Life or VUL Policy
Term Conversion Insert Policy No. and check appropriate Conversion box.
Sections A, C and D (as needed) (Owner of original policy–required on attained age only), E, F (attained age only), G, I and N. Section M (if applicable). If Section C is not completed to indicate otherwise, the Owner will be the Primary Insured, even if he or she is not the Owner of the original policy. The original Policyowner must sign the application.
For additional coverage, complete Sections H, I, J, K and L and provide evidence of insurability per age/amount rules. Refer to PTIS procedures for additional details and requirements. See Agents’ Service and Underwriting Manual. Reinstatements Insert Policy No. and check
“Reinstatement” box.
Requesting a Better Offer (Reduction in Rating)
Insert Policy No. and check “Paid Change Request” box.
Sections A, H, J, and P (Non-Medical Health Questionnaire).
Additional requirements may be required upon underwriting review. See Agents' Service and Underwriting Manual.
For risk amounts less or equal to $1,000,000, complete OFL. For risk amounts more than or equal to $1,000,001, use New Business chart requirement. Reconsideration for Non-Smoker
22861 (2/14)
Insert Policy No. and check “Paid Change Request” box.
Sections A, H, J, and P (Non-Medical Health Questionnaire). Additional requirements may be required upon underwriting review.
See Agents’ Service and Underwriting Manual. Check appropriate
“Exercising a Rider ” box for PPO, GIR, SPO or SPPO and insert Policy No.
Check GIR Face Amount Increase and insert Policy No.
Sections A, C and D (as needed), F, G, H, I, O (not for SPO and SPPO) and the Important Notice: Replacement of Life Insurance or Annuities form. If Section C is not completed to indicate otherwise, the Owner will be the Primary Insured, even if he or she is not the Owner of the original policy. Agent Statement is required.
Sections A, F, G, H, I, O and the Important Notice: Replacement of Life Insurance or Annuities form. Indicate “Increase Face Amount to $_________” in Section Q. Agent Statement is required.
For amounts in excess of option amounts and for rules regarding adding PPO to Custom Whole Life, see Agents' Service and Underwriting Manual. A marriage certificate, birth certificate, and adoption papers are acceptable proofs of events for exercising a Special (Alternative) PPO option. The next regular option is not available if a Special Option is used.
Reinstatement of Lump Sum OPP Insert Policy No. and check "Reinstate OPP" box.
Fully completed Part I and Section P required to apply to reinstate lump sum OPP.
Additional requirements may be required upon underwriting review. See Agent’s Service and Underwriting Manual.
Section A - Primary Insured
Residence Address- If Primary Insured has more than one residence, please provide the address of the residence where the majority of time is spent during the year. A P.O. Box is not acceptable. Details should be provided explaining the locations of the other residences and how much time is spent at each in Section Q.
Social Security or Tax ID Number– If “Applied for”, please provide details in Section Q.
Driver’s License Information- If “None” is answered and Proposed Insured is over age 18, please explain why he/she does not have a driver’s license in Section Q.
Citizenship- Please indicate all countries of citizenship. If multiple citizenship exists, please provide details including amounts of time spent in each country along with the reason for multiple citizenship in Section Q.
Section C - Owner
Complete this section if Owner is to be other than the Primary Insured, or the Proposed Insureds under a dual life plan (e.g., Survivorship, Family Protection). To request additional owner, complete multiple owner question and Section Q, if more space is needed. Provide the best phone number to contact the owner.
A P.O. Box is not acceptable.
Trust information – Complete all Trust questions. Provide the Tax-ID number of the Trust if the owner is a Trust. Also provide address information. Trust must be established prior to app date.
Successor Owner – If a Successor Owner is not named or if no Successor Owner survives the Owner, and the Owner dies before the insured, the Owner’s estate becomes the new Owner. Provide Name, DOB, SS#, address and relationship to PI of successor owner. UTMA/UGMA as Owner – Complete the top of the Owner section with the information for the Custodian of the UTMA/UGMA. Complete the UTMA/UGMA section below that with the information for the child.
Section D - Applicant
Complete this section if Applicant is other than the Primary Insured. If Primary Insured or Additional Insured is a minor, the additional questions in this section must be answered. A P.O. Box is not acceptable. For CPB Applicants and PPB Payers, application Part I, including the Additional Insured page, and an Additional Insured-Non-Medical Health Questionnaire must be completed.
Section E - Payer
Complete this section if the Payer is someone other than the Primary Insured, Owner or Applicant.
Section F - Mode, Policy Date, Premium Financing, Qualified Plans, Premium Notices and Other Requests Chosen Policy Date field is to be utilized for saving age or for requesting a policy date, other than date of issue.
Additional forms are required for Check-O-Matic, Government Allotment, NYL-A-Plan, List Bill, Mainstay and NYLIFE Securities Accounts. NYLife Security account MUST have check writing authority in order for this form of billing to be valid. Billing from NYLife Security accounts require payment of first month premium along with a completed Check-O-Matic form.
Split Dollar – Check the Split Dollar box in Section E and provide the Part A and Part B beneficiary in Section G. Section G - Primary Insured’s Beneficiary
Named Beneficiary Instructions- Always include first, middle (if applicable), and last name. Specify Order, Full Name, Date of Birth, Social Security No./Tax ID No., Address and Telephone Number, Relationship to Insured, and Share (percentage or fraction). Use percentages or fractional shares instead of listing specific dollar amounts. All percentages must total 100% and all fractions must total 1. For Split Dollar, provide the Part A and Part B beneficiary.
The "Per Stirpes" box should not be checked: (1) if all beneficiaries are not to be covered by per stirpes; (2) if a non-person beneficiary (e.g., a trust) is listed; or (3) if there are contingent beneficiaries listed. If per stripes is to apply only to some beneficiaries, then write out "per stirpes" next to the beneficiaries to which it applies.
If FPT Standard beneficiary designation is chosen for the Primary Insured, it applies to all covered on the policy as follows: Insured 1: 1st: Insured 2; 2nd: Children of the Insureds; 3rd: Estate of Insured 1. Insured 2: 1st: Insured 1; 2nd: Children of the Insureds; 3rd: Estate of Insured 2. Child(ren): 1st: Insureds 1 & 2; 2nd; Children of the Insureds.
Trust information– Complete all Trust questions. Trust must be established prior to app date. Section H - Current Health and Payment Information.
The current health questions must be answered for all cases in which deposit premium is taken. Current health questions are not required to be answered for contractual conversions or contractual options, even if a deposit premium is taken. This is because insurability is protected for these requests. Question 4 for Proposed Insureds actual age 24 months old or younger is not required for children under CI Rider and Family Protection Plan.
Section I - Coverage Information
All riders are not available on every plan. Check Agent’s Manual for specific plan and benefit availability. Requests for alternate and additional policies should identify the changes to the original coverage for each alternate or additional requested. Complete plan, face amount, rider(s), rider amount, and dividend option requests. Any further changes should be identified on the instructions line or in Section Q.
CCR Rider- Furnish a completed NYLIC Chronic Care Rider Application Supplement.
Instant Legacy SPUL, Legacy Creator SPVUL– Furnish a Simplified Medical Questionnaire – Part II.
Asset Preserver– Furnish a completed Asset Preserver Application Supplement. Section N - Term Conversions
Use Section Q to provide details for more than two converted policies. Current health questions are not required to be answered for contractual conversions or contractual options, even if a deposit premium is taken. This is because insurability is protected for these requests. If the conversion will be a Point in Scale (PTIS) partial AATC, then Disclosure Form #22584 is required. If it's a PTIS partial AATC of an OCI rider, then Disclosure Form #22588 is required. (To determine if the case qualifies for PTIS, go to the Term Conversion Resource Page through Underwriting link on Agency Portal and click the link for Options for PAATC.)
Section O - Guaranteed Insurability Option Date (PPO and GIR)
Please indicate the reason for exercising the option. Proof of event is required. Additional Insured
To be completed for second insureds under Survivorship and Family Protection plans and for Other Covered Insureds (OCI) and CPB applicants.
Children’s Insurance Information
To be completed only for CI and Family Protection Plan.