EX-99.B(5)(A) 2 a2183071zex-99_b5a.txt EX-99.B(5)(A) Applicants signing in New York must use this form. [LOGO] AMERICAN LEGACY(R) SHAREHOLDER'S ADVANTAGE LINCOLN LIFE & ANNUITY VARIABLE ANNUITY APPLICATION COMPANY OF NEW YORK HOME OFFICE SYRACUSE, NEW YORK All sections must be completed. 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 85. If Trust is owner, trust documents are required. ----------------------------------------------------------- ---------------------------------------------------------------- Name (first, middle initial, last) Social Security Number/TIN / / Male / / Female ----------------------------------------------------------- ---------------------------------------- Street address (physical street address required) Date of birth ----------------------------------------------------------- ---------------------------------------------------------------- City State ZIP Home telephone number Is Trust revocable* ----------------------------------------------------------- ---------------------------------------- / / Yes / / No Trustee name* Date of Trust* 1b JOINT CONTRACT OWNER Maximum age of Joint Contract Owner is 85. ----------------------------------------------------------- ---------------------------------------------------------------- Name (first, middle initial, last) Social Security Number/TIN / / Male / / Female / / Spouse / / Non-Spouse ----------------------------------------------------------- Date of birth 2a ANNUITANT (If no Annuitant is specified, the Contract Owner, or Joint Owner if younger, will be the Annuitant.) Maximum age of Annuitant is 85. ----------------------------------------------------------- ---------------------------------------------------------------- Name (first, middle initial, last) Social Security Number/TIN / / Male / / Female ----------------------------------------------------------- ---------------------------------------- Street address (physical street address required) Date of birth ----------------------------------------------------------- ---------------------------------------------------------------- City State ZIP Home telephone number 2b CONTINGENT ANNUITANT Maximum age of Contingent Annuitant is 85 ----------------------------------------------------------- ---------------------------------------------------------------- Name (first, middle initial, last) Social Security Number/TIN 3 BENEFICIARY(IES) Share percentage must equal 100%. State beneficiaries full legal name. List additional beneficiaries in Section 7. % -------------------------------------------- ------------------------------ ------------------ -------------------- ------- Full legal name / / Primary / / Contingent Relationship to Contract Owner Date of birth SSN/TIN -------------------------------------------------------------------------------------------------------------------------------- Beneficiary address (physical street address required) % -------------------------------------------- ------------------------------ ------------------ -------------------- ------- Full legal name / / Primary / / Contingent Relationship to Contract Owner Date of birth SSN/TIN -------------------------------------------------------------------------------------------------------------------------------- Beneficiary address (physical street address required) % -------------------------------------------- ------------------------------ ------------------ -------------------- ------- Full legal name / / Primary / / Contingent Relationship to Contract Owner Date of birth SSN/TIN -------------------------------------------------------------------------------------------------------------------------------- Beneficiary address (physical street address required) Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 1 of 7 ANF06747NY ALSA-NY 11/07
4 TYPE OF CONTRACT (only choose one) / / NONQUALIFIED: (do NOT select plan type) / / TAX-QUALIFIED (must complete plan type) PLAN TYPE (CHECK ONE): / / Roth IRA / / Traditional IRA / / SEP / / 401(k)* / / 401(a)* / / 457(f) Executive Benefit* / / 457(f) Government/Nonprofit* / / Other --------------------------------------------------- *Additional Qualified Retirement Plan Hold Harmless Agreement Required. 5 REPLACEMENT Must complete this section What is the total amount of annuities and all inforce insurance on your life? (please list in the box below.) If none, check this box: / / ------------------------------------------------------------------------------------------------------------------------------------ Replacement or Check here Face Amount Policy/Contract Issue Date Change of if 1035 Company (life insurance only) Number (mm/dd/yy) Policy/Owner Exchange ------------------------------------------------------------------------------------------------------------------------------------ $ / / Yes / / No / / ------------------------------------------------------------------------------------------------------------------------------------ $ / / Yes / / No / / ------------------------------------------------------------------------------------------------------------------------------------ $ / / Yes / / No / / ------------------------------------------------------------------------------------------------------------------------------------ $ / / Yes / / No / / ------------------------------------------------------------------------------------------------------------------------------------ 6 ADDITIONAL REMARKS --------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------- 7 DECLARATIONS AND SIGNATURES THE ANNUITY WILL BECOME EFFECTIVE ON THE DATE OF ISSUE. IN THE EVENT THE INITIAL PURCHASE PAYMENT IS NOT ACCEPTABLE,THE COMPANY'S LIABILITY IS LIMITED TO THE RETURN OF THE PAYMENT MADE. ANY ANNUITY ISSUED UPON THIS APPLICATION SHALL BE CONSIDERED A CONTRACT OF THE STATE IN WHICH THE CONTRACT IS DELIVERED AND ITS TERMS SHALL BE CONSTRUED IN ACCORDANCE WITH THE LAWS OF THAT STATE. 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 a current prospectus and verify my/our understanding that all payments and values provided by the contract, when based on investment experience of the Variable Account, are variable and not guaranteed as to dollar amount. I/We understand that all payments and values based on the fixed account are subject to an interest adjustment formula that may increase or decrease the value of any transfer, partial surrender, or full surrender from the fixed account made prior to the end of a guaranteed period. 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. ------------------------------------------------ ------------------------------------------------- -------------------------- SIGNATURE OF CONTRACT OWNER SIGNATURE OF JOINT CONTRACT OWNER (IF APPLICABLE) DATE ------------------------------------------------ ------------------------------------------------- Dated at (city and state) Dated at (city and state) ---------------------------------------------------------------------------------------------------- -------------------------- SIGNATURE OF ANNUITANT (ANNUITANT MUST SIGN IF CONTRACT OWNER IS TRUST OR CUSTODIAN.) DATE Page 2 of 7 ANF06747NY 11/07
8 REPRESENTATIVE'S SIGNATURE Does the applicant have any existing life insurance policies or annuity contracts? / / Yes / / No Will the proposed contract replace any existing annuity or life insurance? / / Yes / / No The representative hereby certifies he/she witnessed the signature(s) in Section 7 and 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 Company approved sales materials in conjunction with the 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 of Registered Representative Registered Representative SS# Page 3 of 7 ANF06747NY 11/07