Franklin Valuemark Charter A Flexible Premium Variable Annuity
Issued by Preferred Life Insurance Company of New York GA__________
______________________________________________________________________________
1.OWNER Must be age 85 or younger
Name Last First Middle
________________________________________________________________________
(If the Owner is a trust, please include Trust Name, Trust Date, and the
Trust Beneficial Owner(s))
Address Street Address Apartment Number
City State Zip Code
Social Security Number Date of Birth Sex ____Female
(If the owner is a trust, ____Male
Daytime Telephone ( ) list the date(s) of birth
for the beneficial owner(s))
______________________________________________________________________________
2.JOINT OWNER(Optional)Must be the Spouse of the Owner-Must be age 85 or younger
Name Last First Middle
Social Security Number Date of Birth Sex ____Female
____Male
Daytime Telephone ( )
______________________________________________________________________________
3.ANNUITANT Must be age 85 or younger. Must complete if different than owner.
Name Last First Middle
Address Street Address Apartment Number
City State Zip Code
Social Security Number Date of Birth Sex ____Female
____Male
Daytime Telephone Relationship to Owner
______________________________________________________________________________
4.BENEFICIARY(IES) DESIGNATION
Primary Beneficiary(ies):
(In the event of death of Name Relationship to Owner
the Owner, the surviving
Joint Owner becomes the Name Relationship to Owner
Primary Beneficiary.)
Contingent Beneficiary(ies) Name Relationship to Owner
Name Relationship to Owner
______________________________________________________________________________
5. REPLACEMENT
Is this Annuity intended to replace or change existing life insurance or
annuity? ___Yes ____No
If checked yes, please include the appropriate forms.
______________________________________________________________________________
6. TAX QUALIFIED PLANS
Is this annuity part of a Tax For Tax Qualified Plans, please
Qualified Plan? ____ Yes ____No indicate one of the following:
___IRA ___403(b)TSA
___Roth IRA ___401 (Corporate Plan)
___SEP IRA ___Other _______________
______________________________________________________________________________
7.PURCHASE PAYMENT Minimum Initial Purchase Payment Must Be $25,000.
____Purchase Payment Enclosed with Application
Purchase Payment Amount $_____________________
____This certificate will be funded by a 1035 Exchange, Tax Qualified
Transfer/Rollover, CD or Mutual Fund Redemption. (If checked, please
attach the appropriate forms).
______________________________________________________________________________
8.PURCHASE PAYMENT ALLOCATION
You may select up to 10 funds. Use whole percentages. The allocations
you indicate below will become your allocations on all future payments
until you notify us of a change.
CAPITAL GROWTH FIXED
___%Capital Growth Fund ___%Preferred Life Fixed Account
___%Global Health Care
Securities Fund INCOME
___%Mutual Discovery Securities Fund ___%High Income Fund
___%Natural Resources Securities Fund ___%Xxxxxxxxx Global Income Securities
___%Small Cap Fund Fund
___%Xxxxxxxxx Developing Markets ___%U.S. Government Securities Fund
Equity Fund
___%Xxxxxxxxx Global Growth Fund
___%Xxxxxxxxx International Equity
Fund
___%Xxxxxxxxx International Smaller CAPITAL PRESERVATION AND INCOME
Companies Fund ___%Money Market Fund
___%Xxxxxxxxx Pacific Growth Fund
GROWTH AND INCOME
___%Global Utilities Securities Fund ___TOTAL (Must Equal 100%)
___%Growth and Income Fund
___%Income Securities Fund
___%Mutual Shares Securities Fund
___%Real Estate Securities Fund
___%Rising Dividends Fund
___%Xxxxxxxxx Global Asset Allocation
Fund
___%Value Securities Fund
______________________________________________________________________________
9. Death Benefit Election
Franklin Valuemark Charter automatically includes a "Traditional Death Benefit
that is applicable to certificates owned for the benefit of an individual. The
Traditional Death Benefit is equal to the greater of : 1)Certificate Value or 2)
Purchase Payments less surrenders.
Check the following box if you want to choose the "Enhanced Death Benefit". An
additional charge is assessed to the Owner for this feature. Upon making this
selection, it cannot be changed. This selection can only be made at the time of
initial premium payment. Refer to the Prospectus for additional information.
___Enhanced Death Benefit is equal to the greater of: 1)Certificate Value or 2)
Purchase Payments less surrenders or 3) The highest Anniversary Value prior to
the Owner's 86th birthday. The Anniversary Value is the Certificate Value on a
Certificate anniversary adjusted by subsequent premiums and surrenders.
______________________________________________________________________________
10. INCOME DATE
Selected Income Date ___- 01 -___ The Income Date (Annuitization Date) may be
no earlier than two full certificate years
after the issue date. (If no date is
selected, the Income Date will default to
the later of one month after the Annuitants
90th birthday.)
______________________________________________________________________________
11. BY SIGNING BELOW, THE OWNER UNDERSTANDS THAT 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 sub-accounts may increase or decrease depending on the
certificate's investment results, and that no minimum cash value is guaranteed
on the variable sub-accounts. 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 certificate
to be issued. No representative is authorized to modify this agreement or waive
any of Preferred Life's rights or requirements.
___________________________________ ______________________________________
Owner's Signature(or Trustee, if Joint Owner's Signature (or Trustee,
applicable) if applicable)
___________________________________ ______________________________________
Signed At (City, State) Date Signed
____Please send me a Statement of Additional Information
______________________________________________________________________________
00.XX SIGNING BELOW, THE REGISTERED REPRESENTATIVE/AGENT CERTIFIES THAT
-I am NASD registered and state licensed for variable annuity certificates in
the state where this application is written and delivered; and
-I provided the Owner(s) with the most current Prospectus; and
-To the best of my knowledge and belief, this application ___DOES___DOES NOT
involve replacement of existing life insurance or annuities. If replacement,
attach a copy of each disclosure statement and list of companies involved.
___________________________________ ______________________________________
Registered Representative Name (Print) Registered Representative Name (Print)
___________________________________ ______________________________________
Registered Representative Signature Registered Representative Signature
___________________________________ ______________________________________
Broker Dealer Name Authorized signature of Broker Dealer
if required
______________________________________________________________________________
Branch Address Branch Telephone Number
______________________________________________________________________________
13.MAIL APPLICATIONS TO
Preferred Life-Valuemark Service Center For Overnight Delivery:
c/o PNC Bank Preferred Life Valuemark Service Center
Box 820478 c/o PNC Bank
Philadelphia, PA 19182-0478 Attn: Box 0478
Route 00 xxx Xxxx Xxxx Xxxxx
Xxxxxxxxxx, XX 00000-0478
______________________________________________________________________________
14.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 certificate by the Owner(s); however, any material change
must be accepted in writing by the Owner(s).
