Bankers Life Insurance Co of New York Separate Account I Sample Contracts

Bankers Life Insurance Co of New York Separate Account I – 1. You may not change ownership of this Contract at any time. (December 18th, 1998)

1 EXHIBIT 4(c) BANKERS LIFE INSURANCE COMPANY OF NEW YORK ENDORSEMENT FOR ROTH INDIVIDUAL RETIREMENT ANNUITY This endorsement is attached to and made a part of this Contract. Where a provision of the endorsement conflicts with a provision of the Contract, the provision of the endorsement will govern. This endorsement applies only if the application states this Contract is a Roth Individual Retirement Annuity (Roth IRA). This Contract is issued as a Roth Individual Retirement Annuity under Section 408A of the Internal Revenue Code (Code). To qualify, Your Contract must meet the following requirements: 1. You may not change ownership of this Contract at any time. 2. Your entire interest in the Contract is nonforfeitable. It is established for the exclusive benefit of You or Your beneficiaries. 3. Your Contract is not transferable and may not be used as security for a loan. 4

Bankers Life Insurance Co of New York Separate Account I – READ YOUR CONTRACT CAREFULLY (December 18th, 1998)

1 EXHIBIT 4(a) BANKERS LIFE INSURANCE COMPANY OF NEW YORK 65 Froehlich Farm Boulevard - Woodbury, New York 11797 THE VISIONARY CHOICE VARIABLE ANNUITY READ YOUR CONTRACT CAREFULLY RIGHT TO EXAMINE YOUR CONTRACT. You may cancel and return this Contract to Us for any reason within 10 days after You receive it. You may return the Contract by mailing it to Us at the address of the Service Center shown on page 3. Your Written Request for cancellation must accompany the Contract. If the Contract and the Written Request for cancellation are properly addressed to the Service Center with postage prepaid and if they are postmarked within the 10-day free look period, We will refund to You an amount equal to the sum of: (i) the difference between the Premium Payments paid and the amounts allocated to the Variable Accounts and the Fixed Account

Bankers Life Insurance Co of New York Separate Account I – READ YOUR CONTRACT CAREFULLY (April 1st, 1998)

1 EXHIBIT 4(a) BANKERS LIFE INSURANCE A Member of the COMPANY OF NEW YORK Indianapolis Life Group of Companies 65 Froehlich Farm Boulevard C Woodbury, New York 11797 THE VISIONARY CHOICE VARIABLE ANNUITY READ YOUR CONTRACT CAREFULLY RIGHT TO EXAMINE YOUR CONTRACT. You may cancel and return this Contract to Us for any reason within 10 days after You receive it (20 days if this Contract is replacing another annuity contract or insurance policy). You may return the Contract by mailing it to Us at the address of the Service Center shown on page 4. Your Written Request for cancellation must accompany the Contract. If the Contract and the Written Request for cancellation are properly addressed to the Service Center with postage p