▇▇▇▇ ▇▇▇▇▇▇▇ LIFE INSURANCE COMPANY OF NEW YORK (▇▇▇▇ ▇▇▇▇▇▇▇(R) LOGO)
OVERNIGHT MAILING ADDRESS: ANNUITY SERVICE OFFICE: HOME OFFICE
[▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇ [P.O. Box 9505 [▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇
▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇-6815] Portsmouth, NH 03802-9505] Drive, 2nd Floor
[▇-▇▇▇-▇▇▇-▇▇▇▇] Valhalla, NY 10595]
CONTRACT HOLDER:
CONTRACT DATE: GOVERNING LAW:
THIS IS A LEGAL CONTRACT - READ IT CAREFULLY.
WE AGREE to pay the benefits of the certificates under this Group Contract
(referred to as "this contract") in accordance with their terms and the terms of
this contract. A certificate evidencing participation under this contract will
be issued to each member of the eligible group from which we receive Payment for
the certificate.
THIS CONTRACT is issued in consideration of the master application for this
contract.
SIGNED FOR THE COMPANY at its Home Office, Valhalla, New York, on the Contract
Date.
[/s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇▇] [/s/ ▇▇▇▇▇▇▇ ▇▇▇▇▇]
President Secretary
Group IRA Flexible Payment Deferred Variable Annuity
Guaranteed Lifetime Withdrawal Benefit
Non-Participating
ANNUITY PAYMENTS, DEATH BENEFITS, SURRENDER VALUES AND OTHER VALUES PROVIDED BY
THIS CONTRACT WHEN BASED ON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT ARE
VARIABLE, MAY INCREASE OR DECREASE IN ACCORDANCE WITH THE FLUCTUATIONS IN THE
INVESTEMNT RESULTS, AS APPLICABLE AND NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT.
VENTURE.200.08-GRP-NY PA
TABLE OF CONTENTS
PART 1 - ELIGIBILITY
PART 2 - CERTIFICATES
PART 3 - INCORPORATION
PART 4 - SPECIFICATIONS
PART 5 - TERMINATION
PART 1 ELIGIBILITY
A participant, former participant or beneficiary of a participant or former
participant eligible to purchase an IRA with distributions from a 401(k)
Retirement Plan including a Lifetime Income Benefit. For purposes of the
provisions below, "Participant" means any of the individuals referred to in the
prior sentence.
PART 2 CERTIFICATES
We will issue an individual certificate to each Participant. The certificate
will state the terms, conditions and benefits of this contract.
PART 3 INCORPORATION
Sample certificates attached hereto are made part of this contract. Any
provisions of this contract which are inconsistent with the provisions of the
certificate are waived and superseded by the certificate provisions.
PART 4 SPECIFICATIONS
The Specifications of the certificate will be completed based upon the
information provided by the Participant and the terms of this contract.
PART 5 TERMINATION
This contract will terminate when the contract holder requests termination in
writing to us or when no Participants are insured under any certificate issued
under this contract. Termination of this contract will not affect any
certificates in force on the date of contract termination.
▇▇▇▇ ▇▇▇▇▇▇▇ LIFE INSURANCE COMPANY OF NEW YORK (▇▇▇▇ ▇▇▇▇▇▇▇(R) LOGO)
VENTURE.200.08-GRP SAMPLE
