USAllianz Opportunity
An Individual Flexible Premium Variable Annuity NEW YORK
Issued by Preferred Life Insurance Company of New York GA__________
______________________________________________________________________________
1.CONTRACT OWNER
Name Last First Middle
________________________________________________________________________
(If the Contract Owner is a trust, please include Trust Name, Trust Date,
and the Trust Beneficial Owner(s))
________________________________________________________________________
Street Address Apartment Number e-mail address
________________________________________________________________________
City State Zip Code
Social Security Number ______ Date of Birth __________ Sex ____Female
(If the Contract Owner is a ____Male
Daytime Telephone _______ trust, list the date(s) of birth
for the Trust Beneficial Owner(s))
Are you a U.S. Citizen?__Yes ___No If no, need W8-BEN
______________________________________________________________________________
2.JOINT OWNER(Optional)
Name _____________________________________________________________
Last First Middle
________________________________________________________________________
Street Address Apartment Number e-mail address
________________________________________________________________________
City State Zip Code
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))
Are you a U.S. Citizen?__Yes ___No If no, need W8-BEN
Relationship to Contract Owner _______________ Daytime Telephone _______
______________________________________________________________________________
3.ANNUITANT
Must complete if different than Contract owner.
Name _____________________________________________________________
Last First Middle
________________________________________________________________________
Street Address Apartment Number e-mail address
________________________________________________________________________
City State Zip Code
Social Security Number _______Date of Birth ____________ Sex ____Female
____Male
Relationship to Contract Owner _______________ Daytime Telephone _______
______________________________________________________________________________
4.BENEFICIARY(IES) DESIGNATION
Primary Beneficiary(ies): Contingent Beneficiary(ies)
(At the Contract Owner's
death, the surviving
Joint Owner becomes the
Primary Beneficiary.)
__________________________________ _____________________________________
Name Name
__________________________________ _____________________________________
Relationship to Contract Owner SSN Relationship to Contract Owner SSN
__________________________________ _____________________________________
Name Name
__________________________________ _____________________________________
Relationship to Contract Owner SSN Relationship to Contract Owner SSN
______________________________________________________________________________
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 13 of application.)
______________________________________________________________________________
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 ___Roth IRA Conversion
___Regular IRA Contribution
for Tax Year________
___Roth IRA ___Other _______________
______________________________________________________________________________
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).
______________________________________________________________________________
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
____% AIM V.I. Capital Appreciation
____% AIM V.I. International Equity
____% AIM V.I. Value
XXXXX
____% Xxxxx American MidCap Growth
____% USAZ American Growth
____% USAZ Growth
ALLIANCE CAPITAL
____% USAZ Alliance Capital Growth and Income
____% USAZ Alliance Capital Large Cap Growth
____% USAZ Alliance Capital Technology
AZOA (ALLIANZ OF AMERICA, INC.)
____% AZOA VIP Diversified Assets
____% AZOA VIP Fixed Income
____% AZOA VIP Global Opportunities
____% AZOA VIP Growth
____% AZOA VIP Money Market
XXXXX
____% Xxxxx VA Financial
____% Xxxxx VA Value
XXXXXXXX XXXXXXXXX
____% Xxxxxxxx Global Communications Securities
____% Franklin Growth and Income Securities
____% Franklin High Income
____% Franklin Income Securities
____% Franklin Large Cap Growth Securities
____% Franklin Real Estate
____% Franklin Rising Dividends Securities
____% Xxxxxxxx S&P 500 Index
____% Franklin Small Cap
____% Franklin U.S. Government
____% Franklin Value Securities
____% Franklin Zero Coupon - 2005
____% Franklin Zero Coupon - 2010
____% Mutual Discovery Securities
____% Mutual Shares Securities
____% Xxxxxxxxx Developing Markets Securities
____% Xxxxxxxxx Growth Securities
____% Xxxxxxxxx International Securities
____% USAZ Xxxxxxxxx Developed Markets
XXXXXXXXXXX
____% Xxxxxxxxxxx Global Securities/VA
____% Xxxxxxxxxxx High Income/VA
____% Xxxxxxxxxxx Main Street Growth &
Income/VA
PIMCO
____% PIMCO VIT High Yield Bond
____% PIMCO VIT StocksPLUS Growth andIncome
____% PIMCO VIT Total Return Bond
____% USAZ PIMCO Growth and Income
____% USAZ PIMCO Renaissance
____% USAZ PIMCO Value
XXXXXXXX
____% XX Xxxxxxxx International Growth
____% SP Strategic Partners Focused Growth
SELIGMAN
____% Seligman Global Technology
____% Seligman Small-Cap Value
XXX XXXXXX
____% USAZ Xxx Xxxxxx Aggressive Growth
____% USAZ Xxx Xxxxxx Xxxxxxxx
____% USAZ Xxx Xxxxxx Growth
____% USAZ Xxx Xxxxxx Growth and Income
____% Xxx Xxxxxx LIT Emerging Growth
____% Preferred Life Fixed Account
_____% TOTAL (Must equal 100%)
______________________________________________________________________________
9. 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 Owner(s); however, any material
change must be accepted in writing by the Contract Owner(s).
______________________________________________________________________________
10. 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.
______________________________________________________________________________
11. DEATH BENEFIT (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)
_______________________________________________________________________________
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.)
_______________________________________________________________________________
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.
___________________________________ ______________________________________
Contract Owner's Signature Joint Owner's Signature (or Trustee,
(or Trustee, if 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
oI am NASD registered and state licensed for variable annuity contracts in all
required jurisdictions; and
oI provided the Contract Owner(s) with the most current Prospectus; and
oTo 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.
___________________________________ ______________________________________
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
Comm: A B (circle one)
______________________________________________________________________________
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 0478
Philadelphia, PA 19182-0000 Xxxxx 00& Xxxx Xxxx Xxxxx
Xxxxxxxxxx, XX 00000-0478
______________________________________________________________________________
P40070
