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THE AMERICAN LIFE INSURANCE Flexible Premium Deferred Annuity Policy
COMPANY OF NEW YORK APPLICATION
000 XXXXXX XXXXXX, XXXXXX XXXXX, XXX XXXX, XX
00000
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ANNUITANT'S NAME First Initial Last
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DATE OF BIRTH __MALE INITIAL CONTRIBUTION
/ /
__FEMALE
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OWNER
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NAME OWNER'S SOCIAL SECURITY # OR TAX ID
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ADDRESS Street & Number City State Zip Code
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REPLACEMENT
Is the policy requested by this application intended to replace or change any
insurance or annuities now in force?
___Yes ___No If the answer is "Yes", please provide the following for the
policy being replaced or changed.
Company ___________________________________ Policy Number ________________________________ Amount $_________________________
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ALLOCATION OF CONTRIBUTIONS
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SHORT-TERM INTEREST
ACCUMULATION ACCOUNT % [FUND] % [FUND] % [FUND] % [FUND] %
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[FUND] % [FUND] % [FUND] % [FUND] %
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BENEFICIARY DESIGNATIONS
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Beneficiary Type: __ Primary Beneficiary Type: __ Primary __ Secondary
Relationship: __ Spouse __Child __ Parent Relationship: __ Spouse __ Child __Parent
__Estate __Other __ Estate __Other
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FULL NAME First Initial Last FULL NAME First Initial Last
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DATE OF BIRTH (Optional) Social Security # (Optional DATE OF BIRTH (Optional) Social Security # (Optional)
/ / / /
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XXXXXXX Xxxxxx XXXXXXX Xxxxxx
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Xxxx Xxxxx Zip Code City State Zip Code
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BENEFIT PERCENT % BENEFIT PERCENT %
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STATEMENT AND SIGNATURE
I acknowledge that: (a) I have received a copy of the current Prospectus; (b) I
have read the Prospectus and understand its terms; and (c) I am familiar with
the objectives of the Investment Funds. I understand that any election or
authorization made under made under my FPA Policy as part of this application is
subject to the conditions and limitations set forth in the Prospectus.
I UNDERSTAND THAT: (A) ANY AMOUNTS PLACED IN THE SHORT-TERM INTEREST
ACCUMULATION ACCOUNT WILL EARN INTERST AT THE RATES DETERMINED BY AMERICAN LIFE;
AND (B) ANY AMOUNTS PLACED IN THE INVESTMENT FUNDS ARE NOT GUARANTEED AS TO
FIXED DOLLAR AMOUNTS AND MAY INCREASE OR DECREASE IN VALUE BASED UPON THE FUNDS;
INVESTMENT RESULTS.
All statements in this application are true and complete to the best of my
knowledge and belief. I agree that this application will become a part of any
policy issued based upon this application.
I have determined that the Flexible Premium Deferred Annuity applied for above
is suitable to: (a) my investment objectives; and (b) my financial situation.
An initial payment of $_________ is submitted with this application. I
understand that this premium will be refunded by American Life if a policy based
upon this application is not issued.
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Signature of Owner Date
6576-AX 5/01
