LOGO] PREFERRED LIFE INSURANCE COMPANY OF NEW YORKAnnuity Contract • July 1st, 1999 • Preferred Life Variable Account C • New York
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)) ______________________________________________________________________________Flexible Premium Variable Annuity • July 1st, 1999 • Preferred Life Variable Account C
LOGO]Life Insurance Certificate • July 1st, 1999 • Preferred Life Variable Account C
