0001104659-14-064956 Sample Contracts

JEFFERSON NATIONAL LIFE INSURANCE COMPANY OF NEW YORK Home Office: [Street address is to be determined New York, New York] Administrative Office: [10350 Ormsby Park Place, Louisville, Kentucky 40223] Telephone: [1-866-667-0561] A Stock Company
Insurance Contract • September 5th, 2014 • Jefferson National Life of New York Annuity Account 1 • Kentucky

Jefferson National Life Insurance Company of New York (the “Company”) agrees with the Owner to provide benefits to the Owner, subject to the provisions set forth in this Contract and in consideration of Purchase Payments received from the Owner.

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