LOGO] PREFERRED LIFE INSURANCE COMPANY OF NEW YORKPreferred Life Variable Account C • July 1st, 1999 • New York
Company FiledJuly 1st, 1999 Jurisdiction
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)) ______________________________________________________________________________Preferred Life Variable Account C • July 1st, 1999
Company FiledJuly 1st, 1999