-------------------------------
Lincoln Life & Annuity / American Legacy/(R)/
Company of New York / Shareholder's Advantage
Home office: Syracuse, New York/ Shareholder's Advantage is a variable
------------------------------- annuity contract.
Instructions: Please type or print. ANY ALTERATIONS TO THIS APPLICATION
MUST BE INITIALED BY THE CONTRACT OWNER.
1a. Rights of Accumulation (If additional space is needed, use Section 13.)
/_/ I own an American Funds mutual fund or American Legacy variable
annuity, which may entitle me to a reduced sales charge under the
terms of the prospectus. My account numbers are:____________________
_____________________
/_/ The registration of some of my shares differs. Their account numbers
are (may include spouse and/or children under age 21):
Account no. Name SSN
------------------------ -------------------------- -----------------------
Account no. Name SSN
------------------------ -------------------------- -----------------------
1b. Contract Owner Maximum age of Contract Owner is 89.
_______________________________________ Social Security number/TIN /_//_//_/-/_//_/-/_//_//_//_/
Full legal name or trust name*
Date of Birth /_//_/ /_//_/ /_//_/ /_/ Male /_/ Female
_______________________________________ Month Day Year
Street address
Home telephone number /_//_//_/ /_//_//_/-/_//_//_//_/
_______________________________________
City State Zip
Date of Trust* /_//_/ /_//_/ /_//_/ Is trust revocable?*
_______________________________________ Month Day Year /_/ Yes /_/ No
Trustee name *This information is required for trusts.
1c. Joint Contract Owner Maximum age of Joint Contract Owner is 89.
_______________________________________ Social Security number /_//_//_/-/_//_/-/_//_//_//_/
Full legal name
Date of birth /_//_/ /_//_/ /_//_/ /_/ Male /_/ Female
Month Day Year /_/ Spouse /_/ Non-Spouse
2a. Annuitant (If no Annuitant is specified, the Contract Owner, or Joint Owner if younger, will be the Annuitant.)
Maximum age of Annuitant is 89.
_______________________________________ Social Security number /_//_//_/-/_//_/-/_//_//_//_/
Full legal name
Date of birth /_//_/ /_//_/ /_//_/ /_/ Male /_/ Female
_______________________________________ Month Day Year
Street address
_______________________________________ Home telephone number /_//_//_/ /_//_//_/-/_//_//_//_/
City State Zip
2b. Contingent Annuitant Maximum age of Contingent Annuitant is 89.
_______________________________________ Social Security number /_//_//_/-/_//_/-/_//_//_//_/
Full legal name
3 Beneficiary(ies)) of Contract Owner (List additional beneficiaries on separate sheet. If listing children,
use full legal names.)
____________________________________________________________ ______________________________ __________ _______%
Full legal name or trust name* /_/ Primary /_/ Contingent Relationship to Contract Owner SSN/TIN
____________________________________________________________ ______________________________ __________ _______%
Full legal name or trust name* /_/ Primary /_/ Contingent Relationship to Contract Owner SSN/TIN
____________________________________________________________ ______________________________ __________ _______%
Full legal name or trust name* /_/ Primary /_/ Contingent Relationship to Contract Owner SSN/TIN
____________________________________________________________
Executor/Trustee name* Date of trust* /_//_/ /_//_/ /_//_/ Is trust revocable?*
Month Day Year /_/Yes /_/No
*This information is required for trusts.
To specify an annuity payment option for your beneficiary, please complete the Beneficiary Payment Options form (29953AL-NY).
4 Type of American Legacy Contract
Nonqualified /_/ Initial Contribution OR /_/ 1035 Exchange
Tax-Qualified (must complete plan type): /_/ Initial contribution, Tax Year _________ OR /_/ Transfer OR /_/ Rollover
Plan Type (check one): /_/ Xxxx XXX /_/ Traditional XXX /_/ Non-ERISA 403(b)* (transfers only)
*Indicate plan year end: /_//_/ /_//_/
Month Day
1
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5a Allocation (This section must be completed.)
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Initial minimum: $1,500
Future contributions will follow the allocation below. If DCA option is
selected, the entire amount of each future contribution will follow the
allocation in Section 5b.
If no allocations are specified in Section 5a or 5b, the entire amount will
be allocated to the Cash Management Fund, pending instructions from the
Contract Owner.
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Please allocate my contribution of:
$ ----------------------- OR $ -----------------------
Initial contribution Appropriate amount
from previous carrier
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INTO THE FUND(S) BELOW
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Use whole percentages
% Global Discovery Fund
-----------
% Global Growth Fund
-----------
% Global Small Capitalization Fund
-----------
% Growth Fund
-----------
% International Fund
-----------
% New World Fund
-----------
% Blue Chip Income and Growth Fund
-----------
% Growth-Income Fund
-----------
% Asset Allocation Fund
-----------
% Bond Fund
-----------
% High-Yield Bond Fund
-----------
% U.S. Govt./AAA-Rated Securities Fund
-----------
% Cash Management Fund
-----------
% DCA Fixed Account (must complete 5b)
-----------
% Total (must = 100%)
-----------
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5b Dollar Cost Averaging (Complete only if electing DCA.)
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$1,500 minimum required in the Holding Account
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Total amount to DCA: $ -----------
OR
MONTHLY amount to DCA: $ -----------
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OVER THE FOLLOWING PERIOD: -----------------
MONTHS (6-60)
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FROM THE FOLLOWING HOLDING ACCOUNT (check one):
/_/ DCA Fixed Account
/_/ Cash Management Fund*
/_/ U.S. Govt./AAA-Rated Securities Fund*
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INTO THE FUND(S) BELOW
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Use whole percentages
*The DCA Holding Account
% Global Discovery Fund and the DCA fund elected
----------- cannot be the same.
% Global Growth Fund
-----------
% Global Small Capitalization Fund
-----------
% Growth Fund
-----------
% International Fund
-----------
% New World Fund
-----------
% Blue Chip Income and Growth Fund
-----------
% Growth-Income Fund
-----------
% Asset Allocation Fund
-----------
% Bond Fund
-----------
% High-Yield Bond Fund
-----------
% U.S. Govt./AAA-Rated Securities Fund
-----------
% Cash Management Fund
-----------
% Total (must = 100%)
-----------
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Future contributions will not automatically start a new DCA program.
Instructions must accompany each DCA contribution.
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5c Cross-Reinvestment or Portfolio Rebalancing
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To elect either of these options, please complete the Cross-Reinvestment form
(28051AL-NY and 28065AL-NY) or the Portfolio Rebalancing form (28887).
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Death Benefit Option
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If no benefit is specified, the default Death Benefit will be the Enhanced
Guaranteed Minimum Death Benefit.
/_/ I/We hereby elect the Estate Enhancement Benefit rider, which includes the
Enhanced Guaranteed Minimum Death Benefit.
The Estate Enhancement Benefit rider may only be elected if the contract is
nonqualified and if the Contract Owner, Joint Owner (if applicable) and
Annuitant are all under age 76.
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7 Automatic Withdrawals $10,000 minimum account balance required.
/_/ Please provide me with automatic withdrawals totaling_____% of total contract value or $_________________________
(minimum $50 per distribution/$300 annually), payable as follows:
/_/ Monthly /_/ Quarterly /_/ Semi-annually /_/ Annually Begin withdrawals in /_//_/ /_//_//_//_/
Month Year
Note: If no tax withholding selection is made, federal taxes will be withheld at a rate of 10%. Additional state tax withholding
may be required, depending on state residency.
ELECT ONE: /_/ Do withhold taxes Amount to be withheld______% (must be at least 10%) /_/ Do not withhold taxes
PAYMENT /_/ Direct deposit /_/ Checking(attach a voided check) OR /_/ Savings(attach a deposit slip)
METHOD:
I/We authorize Lincoln Life & Annuity Company of New York to deposit payments to the account and financial institution
identified below. Lincoln Life & Annuity Company of New York is also authorized to initiate corrections, if necessary, to
any amounts credited or debited to my/our account in error. This authorization will remain in effect until my/our funds are
depleted or I/we notify Lincoln Life & Annuity Company of New York of a change in sufficient time to act. This authorization
requires the financial institution to be a member of the National Automated Clearing House Association (NACHA).
__________________________________________________________________________________________________
Bank name Bank telephone number
/_/ Send check to address of record /_/ Send check to the following alternate address:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
8 Automatic Bank Draft
_______________________________________________________________________________________________________
Print account holder name(s) EXACTLY as shown on bank records
_______________________________________________________________________________________________________
Bank name Bank telephone number
$________________________________
Monthly amount Automatic bank draft start date: /_//_/ /_//_/ /_//_/
Month Day(1-28) Year
/_/ Checking (attach a voided check) OR /_/ Savings (attach a deposit slip)
I/we hereby authorize Lincoln Life & Annuity Company of New York to initiate debit entries to my/our account and financial
institution indicated above and to debit the same to such account for payments into annuity contract. This authorization is
to remain in full force and effect until Lincoln Life & Annuity Company of New York has received written notification from
me/us of its termination in such time and manner as to afford Lincoln Life & Annuity Company of New York and the financial
institution a reasonable opportunity to act on it.
9 Replacement
Does the applicant have any existing life policies or annuity contracts? /_/ Yes /_/ No
Will the proposed contract replace any existing annuity or life insurance? /_/ Yes /_/ No
(Attach a state replacement form.)
_______________________________________________________________________________________________________
Company name
_______________________________________________________________________________________________________
Plan name Year issued
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10. Sigantures
All statements made in this application are true to the best of my/our knowledge
and belief, and I/We agree to all terms and conditions as shown. I/We
acknowledge receipt of current prospectuses for American Legacy Shareholder's
Advantage and American Funds Insurance Series/(R)/ and verify my/our
understanding that all payments and values provided by the contract, when based
on investment experiences of the funds in the Series, are variable and not
guaranteed as to dollar amount. Under penalty of perjury, the Contract Owner(s)
certifies that the Social Security (or taxpayer identification) number(s) is
correct as it appears in this application.
______________________________________________ Date [ ][ ] [ ][ ] [ ][ ]
Signed at city State Month Day Year
______________________________________ ________________________________________
Signature of Contract Owner Joint Contract Owner (if applicable)
______________________________________________ Date [ ][ ] [ ][ ] [ ][ ]
Signed at city State Month Day Year
________________________________________________________________________________
Signature of Annuitant (Annuitant must sign if contract owner is a trust or
custodian)
11. Insurance in Force. Will the proposed contract replace any existing annuity
or life insurance contract?
ELECT ONE: [ ] NO [ ] YES
(Attach a state replacement form.)
If yes, please list the insurance in force on the life of the proposed Contract
Owner(s) and Annuitant(s):
___________________________________________________ $________________________
Company Name Year Issued Amount
12. Additional Remarks
________________________________________________________________________________
13. American Funds/American Legacy Total Account Value (For Rights of
Accumulation purposes.)
My client owns a total of $___________ in the American Funds mutual funds and/or
American Legacy variable annuity products. NOTE: Please include the deposit for
the purchase of this contract.
14. Dealer Information Licensing appointment with Lincoln Life & Annuity
Company of New York is required for this application to be processed. If
more than one representative, please indicate names and percentages in
Section 12.
[ ] Income4Life/(R)/ Solution - complete Form 30350AL (nonqualified) or Form
30350Q-AL (qualified)
_____________________________________________ [ ][ ][ ] [ ][ ][ ]-[ ][ ][ ][ ]
Registered representative's name Registered representative's
(print as it appears on NASD licensing) telephone number
_____________________________________________ [ ][ ][ ]-[ ][ ]-[ ][ ][ ][ ]
Client account number at dealer Registered representative's SSN
(if applicable)
________________________________________________________________________________
Dealer's Name
________________________________________________________________________________
Branch address City State Zip
[ ] CHECK IF BROKER CHANGE OF ADDRESS Rep code at Firm ________________________
15. Representative's Signature
The representative hereby certifies that he/she witnessed the signature(s) in
Section 10 and that all information contained in this application is true to the
best of his/her knowledge and belief. The representative also certifies that
he/she has used only Lincoln Life & Annuity Company of New York approved sales
materials in conjunction with this sale; and copies of all sales materials were
left with the applicant(s). Any electronically presented sales material shall
be provided in printed form to the applicant no later than at the time of the
policy or the contract delivery.
________________________________________________________________________________
Signature
Send completed application - with a check made payable to Lincoln Life & Annuity
Company of New York - to your investment dealer's home office or to:
Lincoln Life and Annuity Company of New York
Servicing Office - X.X. Xxx 0000
Xxxx Xxxxx, XX 00000-0000
By Express Mail:
Lincoln Life & Annuity Company of New York
Attention: American Legacy Operations
0000 Xxxxx Xxxxxxx Xxxxxx
Xxxx Xxxxx, XX 00000
If you have any questions regarding this application, call Lincoln Life &
Annuity Company of New York at 000-000-0000.
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