[USAllianz Opportunity TM]
An Individual Flexible Premium Fixed and Variable Annuity NEW YORK
Issued by Preferred Life Insurance Company of New York GA__________
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1.CONTRACT OWNER
Name
Last First Middle
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(If the Contract Owner is a trust, please include Trust Name, Trust Date,
and the Trust Beneficial Owner(s))
Address
Street Address Apartment Number e-mail Address
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City State Zip Code
Are you a U.S. Citizen?__Yes ___No
If no, need W8-BEN Social Security Number ___________
Date of Birth _________________ Sex ____Female ____Male
(If the Contract Owner is a trust, list the Date(s) of Birth for the
Trust Beneficial Owner(s). Daytime Telephone (___)__________________
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2.JOINT OWNER(Optional)
Name
Last First Middle
Address
Street Address Apartment Number e-mail Address
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City State Zip Code
Are you a U.S. Citizen?__Yes ___No
If no, need W8-BEN
Social Security Number _____________
Date of Birth ____________ Sex ____Female ____Male
(If the Contract Owner is a trust,list the Date(s) of Birth for the
Trust Beneficial Owner(s).
Relationship to Contract Owner ___________ Daytime Telephone (___)________
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3.ANNUITANT (Must complete if different than Contract Owner.)
Name
Last First Middle
Address
Street Address Apartment Number e-mail Address
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City State Zip Code
Social Security Number _____________
Date of Birth ____________ Sex ____Female ____Male
Relationship to Contract Owner ____________ Daytime Telephone (___)_______
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4.BENEFICIARY(IES) DESIGNATION
Primary Beneficiary(ies): Contingent Beneficiary(ies)
(At the Contract Owner's death,
the Surviving Joint Owner becomes
the Primary Beneficiary.)
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Name Name
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Relationship to Contract Owner SSN Relationship to Contract Owner SSN
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Name Name
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Relationship to Contract Owner SSN Relationship to Contract Owner SSN
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5. REPLACEMENT
Is this annuity intended to replace or
change existing life insurance or annuity? ___Yes - Please include appropriate
form.
___ No
(The Registered Representative must answer another replacement question in
section 14 of application.)
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6. TAX QUALIFIED PLANS
Is this annuity part of a Tax Qualified Plan?
____ Yes ____No If yes, please select one of the following:
___IRA Transfer/Rollover
___Regular Contribution for Tax Year________
___Roth IRA Conversion
___Other _______________
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7.PURCHASE PAYMENT
____Purchase Payment Enclosed with Application
Purchase Payment Amount $_____________________
____This contract will be funded by a 1035 exchange, Tax-Qualified
Transfer/Rollover, CD Transfer or Mutual Fund Redemption.(If checked,
please include the appropriate forms).
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8.PURCHASE PAYMENT ALLOCATION
You may select up to 10 Investment Options. Use whole percentages. Total
must equal 100%. The allocations you indicate below will become your
allocations on all future payments until you notify us of a change.
AIM
____% USAZ AIM Basic Value ____% Mutual Shares Securities
____% USAZ AIM Blue Chip ____% Xxxxxxxxx Developing Markets
____% USAZ AIM Dent Demographic Trends Securities
____% USAZ AIM International Equity ____% Xxxxxxxxx Foreign Securities
ALLIANCE CAPITAL ____% Xxxxxxxxx Growth Securities
____% USAZ Alliance Capital Growth and ____% USAZ Xxxxxxxxx Developed Markets
Income XXXXXXXX
____% USAZ Alliance Capital Large Cap ____% Xxxxxxxx 20/20 Focus
Growth ____% XX Xxxxxxxx International Growth
____% USAZ Alliance Capital Technology ____% SP Strategic Partners Focused
XXXXX Growth
____% Xxxxx VA Financial XXXXXXXXXXX
____% Xxxxx VA Value ____% Xxxxxxxxxxx Global Securities/VA
DREYFUS ____% Xxxxxxxxxxx High Income/VA
____% Dreyfus Small Cap Stock Index ____% Xxxxxxxxxxx Main Street Growth &
____% Dreyfus Stock Index Income/VA
FRANKLIN XXXXXXXXX ____% USAZ Xxxxxxxxxxx Emerging Growth
____% Franklin Global Communications Securities
____% Franklin Growth and Income PIMCO
Securities ____% PIMCO VIT High Yield
____% Franklin High Income ____% PIMCO VIT StocksPLUS Growth
____% Franklin Income Securities and Income
____% Franklin Large Cap Growth ____% PIMCO VIT Total Return
Securities ____% USAZ PIMCO Growth and Income
____% Franklin Real Estate ____% USAZ PIMCO Renaissance
____% Franklin Rising Dividends ____% USAZ PIMCO Value
Securities SELIGMAN
____% Franklin Small Cap ____% Seligman Small-Cap Value
____% Franklin U.S.Government XXX XXXXXX
____% Franklin Small Cap Value ____% USAZ Xxx Xxxxxx Aggressive Growth
Securities ____% USAZ Xxx Xxxxxx Xxxxxxxx
____% Franklin Zero Coupon - 2005 ____% USAZ Xxx Xxxxxx Emerging Growth
____% Franklin Zero Coupon - 2010 ____% USAZ Xxx Xxxxxx Growth
____% Mutual Discovery Securities ____% USAZ Xxx Xxxxxx Growth and Income
____% USAZ Money Market
____% Preferred Life Fixed Account (YOU CANNOT SELECT THE FIXED ACCOUNT IF YOU
SELECT THE GUARANTEED MINIMUM INCOME BENEFIT)
____% TOTAL (Must equal 100%)
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9. INCOME DATE
Selected Income Date ___- 01 -___ The Income Date (Annuitization Date) may be
no earlier than 13 months from the Issue
Date. The maximum annuitization age of the
Annuitant is age 90.
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Home Office Use Only
If Preferred Life Insurance Company of New York makes a change in this space in
order to correct any apparent errors or omissions, it will be approved by
acceptance of this contract by the Contract Owner(s); however, any material
change must be accepted in writing by the Contract Owner(s).
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10. DEATH BENEFIT OPTIONS(Choose one of the following Death Benefit options.
Upon making your selection, it cannot be changed.
_____ Traditional Death Benefit (If you do not check either box, this will be
the Death Benefit on the Contract.)
_____ Enhanced Death Benefit (Optional)(The Contract Owner must be 80 or
younger to select this option.)
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11. GUARANTEED MINIMUM INCOME BENEFIT (Choose the following. Upon making your
selection, it cannot be changes.)
_____ Guaranteed Minimum Income Benefit (Optional) (If you do not choose this
box, you will not receive this benefit.) (YOU CANNOT SELECT THE PREFERRED
LIFE FIXED ACCOUNT IF YOU SELECT THIS BENEFIT.)
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12. PROSPECTUS REPORT AND DELIVERY
_____I would like to receive electronic, rather than paper copies of contract
prospectuses, fund prospectuses, and periodic reports for all USAllianz products
that I own, acquire, or apply for, and hereby consent to electronic delivery.
Electronic delivery will be effected via the USAllianz website. I have been
informed that current copies of prospectuses for currently available USAllianz
products and prospectuses for underlying funds are available at
xxx.xxxxxxxxx.xxx. I have also been informed that I will be notified when new,
updated prospectuses and reports for contracts I own or acquire become
available. I acknowledge that I have the ability to access and download this
information.
If I choose, in the future I can revoke this consent and receive paper copies.
(If the box is not checked, then your Prospectus will be mailed.)
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13. BY SIGNING BELOW, THE CONTRACT OWNER UNDERSTANDS AND OR AGREES TO
I received a Prospectus and have determined that the variable annuity applied
for is not unsuitable for my insurance investment objectives, financial
situation, and financial needs. It is a long term commitment to meet insurance
needs and financial goals. I understand that the annuity value for payments
allocated to the variable investment options may increase or decrease depending
on the contract's investment results, and that no minimum cash value is
guaranteed on the variable investment options. To the best of my knowledge and
belief, all statements and answers in this application are complete and true. It
is further agreed that these statements and answers will become a part of any
contract to be issued. No representative is authorized to modify this agreement
or waive any of Preferred Life's rights or requirements.
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Contract Owner's Signature Joint Owner's Signature (or Trustee,
(or Trustee, if applicable) if applicable)
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Signed At (City, State) Date Signed
____Please send me a Statement of Additional Information
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00.XX SIGNING BELOW, THE REGISTERED REPRESENTATIVE/AGENT CERTIFIES THAT
o I am NASD registered and state licensed for variable annuity contracts in all
required jurisdictions; and
o I provided the Contract Owner(s) with the most current Prospectus; and
o To the best of my knowledge and belief, this application
___DOES___DOES NOT involve replacement of existing life insurance or
annuities. If replacement, include a copy of each disclosure statement and
list of companies involved.
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Registered Representative Name (Print) Registered Representative Name (Print)
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Registered Representative Signature Registered Representative Signature
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Broker Dealer Name Authorized signature of Broker Dealer
if required
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Branch Address Branch Telephone Number
Comm: A B (circle one)
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14.MAIL APPLICATIONS TO
For Regular Mail: For Overnight Delivery:
Preferred Life-USAllianz Service Center Preferred Life-USAllianz Service Center
c/o PNC Bank c/o PNC Bank
P.O. Box 820478 Attn: Box 4278
Philadelphia, PA 19182-0000 Xxxxx 00 & Xxxx Xxxx Xxxxx
Xxxxxxxxxx, XX 00000-0478
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P40070 (11-02)
