------------------------------- Applicants signing in New York must use this form.
Lincoln Life & Annuity American Legacy(R)
Company of New York Shareholder's Advantage
Home office: Syracuse, New York Shareholder's Advantage is a variable annuity contract.
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Instructions: Please type or print. ANY ALTERATIONS TO THIS APPLICATION MUST BE INITIALED BY THE CONTRACT OWNER.
1a Contract Owner Maximum age of Contract Owner is 89.
Social Security number/TIN [_][_][_]-[_][_]-[_][_][_][_]
____________________________________________________________
Full legal name or trust name*
Date of birth [_][_] [_][_] [_][_] [_] Male [_] Female
Month Day Year
____________________________________________________________
Street address
(If PO Box, physical street address required)
Home telephone number [_][_][_]/[_][_][_]-[_][_][_][_]
____________________________________________________________
City State ZIP
Date of trust* [_][_] [_][_] [_][_] Is trust revocable?*
Month Day Year [_] Yes [_] No
____________________________________________________________
Trustee name*
*This information is required for trusts.
1b Joint Contract Owner Maximum age of Joint Contract Owner is 89.
Social Security number [_][_][_]-[_][_]-[_][_][_][_]
____________________________________________________________
Full legal name
Date of birth [_][_] [_][_] [_][_] [_] Male [_] Female
Month Day Year
[_] Spouse [_] Non-spouse
2a Annuitant (If no Annuitant is specified, the Contract Owner, or Joint Owner if younger, will be the Annuitant.)
Maximum age of Annuitant is 89.
Social Security number [_][_][_]-[_][_]-[_][_][_][_]
____________________________________________________________
Full legal name
Date of birth [_][_] [_][_] [_][_] [_] Male [_] Female
Month Day Year
____________________________________________________________
Street address
Home telephone number [_][_][_]/[_][_][_]-[_][_][_][_]
____________________________________________________________
City State ZIP
2b Contingent Annuitant Maximum age of Contingent Annuitant is 89.
Social Security number [_][_][_]-[_][_]-[_][_][_][_]
____________________________________________________________
Full legal name
3 Beneficiary(ies) of Contract Owner (List additional Beneficiaries on separate sheet.
If listing children, use full legal names.)
____________________________________________________________ __________________________________ ______________ _______%
Full legal name or trust name* [_] Primary [_] Contingent Relationship to Contract Owner SSN/TIN
____________________________________________________________ __________________________________ ______________ _______%
Full legal name or trust name* [_] Primary [_] Contingent Relationship to Contract Owner SSN/TIN
____________________________________________________________ __________________________________ ______________ _______%
Full legal name or trust name* [_] Primary [_] Contingent Relationship to Contract Owner SSN/TIN
____________________________________________________________ Date of trust* [_][_] [_][_] [_][_] Is trust revocable?*
Executor/Trustee name* Month Day Year [_] Yes [_] No
*This information is required for trusts.
To specify an annuity payment option for your beneficiary, please complete the Beneficiary Payment Options form (29953AL-NY).
4 Type of American Legacy Contract
Nonqualified: [_] Initial contribution OR [_] 1035 exchange
Tax-qualified (must complete plan type): [_] Initial contribution, tax year________ OR [_] Transfer (to same market) OR
[_] Rollover (to different market)
Plan type (check one): [_] Xxxx XXX [_] Traditional XXX
[_] Non-ERISA 403(b)/+/ (transfers only) /+/Indicate plan year-end: [_][_] [_][_]
Month Day
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5a Allocation (This section must be completed.) 5b Dollar Cost Averaging (Complete only if electing DCA.)
Initial minimum: $1,500 $1,500 minimum required in the holding account
Future contributions will follow the allocation below. ------------------------------------------------------------
If DCA option is selected, the entire amount of each Total amount to DCA: $ _____________
future contribution will follow the allocation in OR
Section 5b. MONTHLY amount to DCA: $ _____________
------------------------------------------------------------
If no allocations are specified in Section 5a or 5b, the OVER THE FOLLOWING PERIOD: __________________
entire amount will be allocated to the Cash Management MONTHS (6-60)
Fund, pending instructions from the Contract Owner. ------------------------------------------------------------
----------------------------------------------------------- FROM THE FOLLOWING HOLDING ACCOUNT (check one):
Please allocate my contribution of: [_] DCA Fixed Account
$ ____________________ OR $ ___________________ [_] Cash Management Fund/1/
Initial contribution Approximate amount [_] U.S. Govt./AAA-Rated Securities Fund/1/
from previous carrier
----------------------------------------------------------- ------------------------------------------------------------
INTO THE FUND(S) BELOW Use whole percentages INTO THE FUND(S) BELOW Use whole percentages
----------------------------------------------------------- ------------------------------------------------------------
__________ % Global Discovery Fund /1/ The DCA holding account
__________ % Global Growth Fund and the DCA fund elected
__________ % Global Small Capitalization Fund cannot be the same.
__________ % Growth Fund __________ % Global Discovery Fund
__________ % International Fund __________ % Global Growth Fund
__________ % New World Fund __________ % Global Small Capitalization Fund
__________ % Blue Chip Income and Growth Fund __________ % Growth Fund
__________ % Growth-Income Fund __________ % International Fund
__________ % Asset Allocation Fund __________ % New World Fund
__________ % Bond Fund __________ % Blue Chip Income and Growth Fund
__________ % High-Income Bond Fund __________ % Growth-Income Fund
__________ % U.S. Govt./AAA-Rated Securities Fund __________ % Asset Allocation Fund
__________ % Cash Management Fund __________ % Bond Fund
__________ % DCA Fixed Account (must complete 5b) __________ % High-Income Bond Fund
__________ % U.S. Govt./AAA-Rated Securities Fund/1/
========== % Total (must = 100%) __________ % Cash Management Fund/1/
========== % Total (must = 100%)
------------------------------------------------------------
Future contributions will not automatically start a new
DCA program. Instructions must accompany each DCA
contribution.
---------------------------------------------------------------- ------------------------------------------------------------
5c Cross-Reinvestment or Portfolio Rebalancing
To elect either of these options, please complete the Cross-Reinvestment
form (28051AL-NY) or the Portfolio Rebalancing form (28887AL-NY).
6 Benefit Options
Death benefits
Select one: (If no benefit is specified, the default death benefit will be
the Guarantee of Principal death benefit.)
[_] I/We hereby elect the Enhanced Guaranteed Minimum Death Benefit.
[_] I/We hereby elect the Guarantee of Principal death benefit.
Living benefit
[_] I/We hereby elect the Principal Security Benefit/2/ option.
/2/If the contract is tax-qualified, maximum age is 80. For XXX contracts,
the annual amount available for withdrawal under the Principal Security
Benefit may not be sufficient to satisfy the minimum distributions required
by law beginning at age 70 1/2. Therefore, the owner may be required to
make withdrawals that exceed the Annual Withdrawal Limit. Withdrawals in
excess of the Annual Withdrawal Limit may quickly and substantially
decrease the amount guaranteed by the Principal Security Benefit,
especially in a declining market. If this contract is intended for use as
an XXX contract, you should consider whether the Principal Security Benefit
is appropriate for your circumstances. You should consult your tax advisor.
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7 Automatic Withdrawals $10,000 minimum account balance is required.
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[_] Please provide me with automatic withdrawals totaling _____% of total contract value or $_________________
(Withdrawal minimums: $50 per distribution/$300 annually), payable as follows:
[_] Monthly [_] Quarterly [_] Semi-annually [_] Annually Begin withdrawals in [_][_] [_][_][_][_]
Month Year
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Note: If no tax withholding selection is made, federal taxes will be
withheld at a rate of 10%. Additional state tax withholding may be
required, depending on state of residency.
ELECT ONE: [_] Do withhold taxes Amount to be withheld ____% (must be at least 10%)
[_] Do not withhold taxes
PAYMENT
METHOD: Direct deposit [_] Checking (attach a voided check) OR [_] Savings (attach a deposit slip)
I/We authorize Lincoln Life & Annuity Company of New York to
deposit payments to the account and financial institution
identified below. Lincoln Life & Annuity Company of New York is
also authorized to initiate corrections, if necessary, to any
amounts credited or debited to my/our account in error. This
authorization will remain in effect until my/our funds are depleted
or I/we notify Lincoln Life & Annuity Company of New York of a
change in sufficient time to act. This authorization requires the
financial institution to be a member of the National Automated
Clearing House Association (NACHA).
__________________________________________________________________________________________________________________
Bank name Bank telephone number
8 Automatic Bank Draft
________________________________________________________________ _______________________________________________________
Print account holder name(s) EXACTLY as shown on bank records
__________________________________________________________________________________________________________________________
Bank name Bank telephone number
$______________________________
Monthly amount Automatic bank draft start date: [_][_] [_][_] [_][_]
Month Day(1-28) Year
[_] Checking (attach a voided check) OR [_] Savings (attach a deposit slip)
I/We hereby authorize Lincoln Life & Annuity Company of New York to
initiate debit entries to my/our account and financial institution
indicated above and to debit the same to such account for payments into
an annuity contract. This authorization is to remain in full force and
effect until Lincoln Life & Annuity Company of New York has received
written notification from me/us of its termination in such time and
manner as to afford Lincoln Life & Annuity Company of New York and the
financial institution a reasonable opportunity to act on it.
9 Replacement
Does the applicant have any existing life policies or annuity contracts?
[_] Yes [_] No
Will the proposed contract replace any existing annuity or life insurance?
[_] Yes [_] No
(Attach a state replacement form.)
__________________________________________________________________________________________________________________________
Company name
_____________________________________________________________________________ __________________________________________
Plan name Year issued
10 Signatures
From time to time, interest credited to amounts allocated to the six-, 12-,
or 24-month Dollar Cost Averaging Fixed Account will exceed our actual
earnings on supporting assets, less appropriate risk and expense
deductions. We will recover amounts credited over amounts earned from the
mortality and expense risk charges described in your contract. Your
contract charges will not increase as a result of these higher interest
rates being credited to the Dollar Cost Averaging Fixed Account.
We also offer other types of annuities, with different fee structures,
including some that offer lower fees. You should carefully consider whether
this contract is the best product for you. All fees and features for this
product are fully described in the contract and prospectus.
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10 Signatures (continued)
All statements made in this application are true to the best of my/our
knowledge and belief, and I/we agree to all terms and conditions as shown.
I/We acknowledge receipt of current prospectuses for American Legacy
Shareholder's Advantage and American Funds Insurance Series(R) and verify
my/our understanding that all payments and values provided by the contract,
when based on investment experience of the funds in the Series, are
variable and not guaranteed as to dollar amount. Under penalty of perjury,
the Contract Owner(s) certifies that the Social Security (or taxpayer
identification) number(s) is correct as it appears in this application.
_______________________________________________________________________________________
Signed at city State
Date [_][_] [_][_] [_][_]
Month Day Year
_______________________________ ____________________________________________________
Signature of Contract Owner Joint Contract Owner (if applicable)
_______________________________________________________________________________________
Signed at city State
Date [_][_] [_][_] [_][_]
Month Day Year
_______________________________________________________________________________________
Signature of Annuitant (Annuitant must sign if Contract Owner is a trust or custodian.)
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THE FOLLOWING SECTIONS MUST BE COMPLETED BY THE SECURITIES DEALER OR FINANCIAL ADVISER. Please type or print.
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11 Insurance in Force Will the proposed contract replace any existing annuity or life insurance contract?
ELECT ONE: [_] No [_] Yes If yes, please list the insurance in force on the life of the
proposed Contract Owner(s) and Annuitant(s):
(Attach a state replacement form.)
$
__________________________________________________________________________________________________________________________
Company name Year issued Amount
12 Additional Remarks
__________________________________________________________________________________________________________________________
13 Dealer Information Licensing appointment with Lincoln Life & Annuity Company of New York is required for this
application to be processed. If more than one representative, please indicate names and percentages
in Section 12.
___________________________________________________________________________ [_][_][_]/[_][_][_]-[_][_][_][_]
Registered representative's name (print as it appears on NASD licensing) Registered representative's telephone number
___________________________________________________________________________ [_][_][_]-[_][_]-[_][_][_][_]
Client account number at dealer (if applicable) Registered representative's SSN
__________________________________________________________________________________________________________________________
Dealer's name
__________________________________________________________________________________________________________________________
Branch address City State ZIP
[_] CHECK IF BROKER CHANGE OF ADDRESS Rep code at firm _______________________________________________________________
14 Representative's Signature
The representative hereby certifies that all information contained in this
application is true to the best of his/her knowledge and belief. The
representative also certifies that he/she has used only Lincoln Life &
Annuity Company of New York approved sales materials in conjunction with
this sale and copies of all sales materials were left with the
applicant(s). Any electronically presented sales material shall be provided
in printed form to the applicant no later than at the time of the policy or
the contract delivery.
__________________________________________________________________________________________________________________________
Signature
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Send completed application -- with a check made payable to Lincoln Life &
Annuity Company of New York -- to your investment dealer's home office or to:
Lincoln Life & Annuity Company of New York By Express Mail: Lincoln Life & Annuity Company of New York
Servicing Office - P.O. Box 2348 Attention: American Legacy Operations
Xxxx Xxxxx, XX 00000-0000 0000 Xxxxx Xxxxxxx Xxxxxx
Xxxx Xxxxx, XX 00000
If you have any questions regarding this application, please call Lincoln Life &
Annuity Company of New York at 000 000-0000.
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