Exhibit 5(a)
APPLICATION New York Life IndexFlex For Individual Variable Single Annuity Premium Variable Annuity with an Index-Linked Account New York Life Insurance and Annuity Corporation (NYLIAC) (A Delaware Corporation)
Mailing Address*: New York Life, PO Box 6916, Cleveland, OH 44101
New York Life, PO Box 130539, Dallas, TX 75313
*See application instructions to determine the appropriate mailing address for this application.
ANNUITY COMMENCEMENT DATE AT AGE 95
Please print or type
1. SURRENDER CHARGE PERIOD
Choose ONE:
5 Year Surrender Charge Period 6 Year Surrender Charge Period 7 Year Surrender Charge Period
If Surrender you elect Charge an Initial Period Term you Strategy elect, on as the long Premium as account Allocation value remains Form, the in the applicable Initial Term Flat Strategy. Rate or Cap Rate is guaranteed through the
2. OWNER
Individual Trust Corporation Mr. Mrs. Ms. Male Grantor Trust Partnership Other: Miss Rev. Dr. Female First Name or Trust/Corporation Name Middle Last Name Suffix
Mailing Address
Street or P.O. Box City State Zip Code
Residence Address (if different from mailing address)
Street City State Zip Code Social Security/Tax I.D. Number Date of Birth (mm/dd/yyyy) Date of Trust and State
Country of Citizenship If you checked “Other” under Country of Relationship to Annuitant U.S. Citizenship, are you a U.S. Resident Alien? Self Spouse Other, Country Name: Yes No Other:
Relationship to Joint Annuitant (if any) Telephone Number Cell Home Business Email Address Self Spouse Other:
eDelivery Acknowledgement
By entering an e-mail address above, I am agreeing to be contacted by New York Life to receive a link to sign-up for e-mail delivery (eDelivery) of any or all of the following: Prospectuses, Annual Reports, Semi-Annual Reports, Quarterly Policy Summaries, Consolidated Statements, and Tax Forms for all accounts registered under my Social Security/Tax Identification Number. I understand that, once I agree to eDelivery, an e-mail will be sent to me when any of the documents are available on the New York Life website – www.newyorklife.com. I understand that I may change my e-mail address or mail preferences by logging into my account at www.newyorklife.com. I understand that if New York Life cannot obtain a valid e-mail address, the documents will be delivered to me by U.S. mail.
3. JOINT OWNER
Available for Non-Qualified Policy Type ONLY.
Mr. Mrs. Ms. Male
Miss Rev. Dr. Female
First Name Middle Last Name Suffix
Mailing Address
Street or P.O. Box City State Zip Code
Residence Address (if different from mailing address)
Street City State Zip Code
Social Security Number Date of Birth (mm/dd/yyyy)
Country of Citizenship Relationship to Owner
U.S. Spouse
Other, Country Name: Other:
Relationship to Annuitant Relationship to Joint Annuitant (if any)
Self Spouse Other: Self Spouse Other:
Telephone Number Cell Home Business Email Address
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4. APPLICANT
If same as Owner, check here . If same as Joint Owner, check here . Otherwise, complete this section.
Mr. Mrs. Ms. Male Date of Birth (mm/dd/yyyy)
Miss Rev. Dr. Female
First Name or Trust/Corporation Name Middle Last Name Suffix
Mailing Address
Street or P.O. Box City State Zip Code
Residence Address (if different from mailing address)
Street City State Zip Code
Country of Citizenship Social Security/Tax I.D. Number Relationship to Owner
U.S. Spouse
Other, Country Name: Other:
Telephone Number Cell Home Business Email Address
5. ANNUITANT
Complete this section if the Annuitant is not the Owner or Joint Owner.
Male Date of Birth (mm/dd/yyyy)
Female Proof of Age Required
First Name Middle Last Name Suffix
Residence Address (Required)
Street City State Zip Code
Social Security Number Country of Citizenship
U.S.
Other, Country Name:
Telephone Number Cell Home Business Email Address
6. JOINT ANNUITANT
Complete this section if the Joint Annuitant is not the Owner or Joint Owner. Not available for Inherited IRA Policy Type.
Male Date of Birth (mm/dd/yyyy)
Female Proof of Age Required
First Name Middle Last Name Suffix
Residence Address (Required)
Street City State Zip Code
Social Security Number Country of Citizenship
U.S.
Other, Country Name:
Telephone Number Cell Home Business Email Address
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7. BENEFICIARY DESIGNATION
Note: Primary and Contingent Beneficiary designations must each total 100%. If percentage(s) are not provided, the benefits will be divided equally. For a per stirpes Beneficiary designation, write “Per Stirpes” next to each applicable Beneficiary’s name. Use Section 10 to enter additional Beneficiary information. Refer to the application instructions for further details. If the Beneficiary is a minor, also complete the UTMA/UGMA fields below.
For Traditional, Roth and SEP IRA Policy Types: Please note that available death benefit payout options differ depending on whether your designated Beneficiary is eligible or non-eligible (determined as of the date of your death) under the Internal Revenue Code (“IRC”). Eligible designated Beneficiaries are spouses, children under the age of majority, disabled or chronically ill individuals, as determined by the IRC, (including certain trusts for the disabled or chronically ill), or individuals who are not more than 10 years younger than you. All other individual Beneficiaries are non-eligible, and all proceeds must be distributed to them by the end of the 10th year following the year of your death (or the death of both you and the joint annuitant, if applicable).
For Inherited IRA Policy Type: After your death, your Beneficiaries may be limited to a distribution period that does not exceed 10 years from the end of the year following the year of death of the original IRA owner or retirement plan participant.
JOINT OWNERS WHO ARE SPOUSES:
Unless you check the box below, your spouse will be the sole Primary Beneficiary of the Policy and no other primary beneficiary should be designated. This allows the surviving Owner/spouse to continue the Policy at the death of the other Owner before the Annuity Commencement Date.
ONE OWNER:
Unless you check the box below, your spouse will be the sole Primary Beneficiary of the Policy and no other primary beneficiary should be designated. This allows your spouse to continue the Policy if you die before the Annuity Commencement Date. If your spouse’s information is not listed in the sections above, please provide his/her information below.
Regardless of your primary beneficiary designation, you may name contingent beneficiary(ies) below.
DECLINING TO DESIGNATE SURVIVING SPOUSE AS THE SOLE PRIMARY BENEFICIARY:
By individual(s)/entity(ies) checking this box, I am named NOT below. naming As my a result, spouse the as Policy sole Primary will end Beneficiary at the death and of any instead Owner designate before the the Annuity Commencement Date and NYLIAC will pay a death benefit.
JOINT OWNERS WHO ARE NOT SPOUSES:
The surviving Owner is the sole Primary Beneficiary. No other primary beneficiary should be designated however, you may name contingent beneficiary(ies) below. The Policy will end at the death of the other Owner.
PRIMARY or CONTINGENT Beneficiary’s Full Name/Entity Name Date of Birth Social Security/ Percentage
(mm/dd/yyyy) Tax I.D. Number
%
Address: Street City State Zip Code
Email Address Telephone Number Relationship to Owner
PRIMARY or CONTINGENT Beneficiary’s Full Name/Entity Name Date of Birth Social Security/ Percentage
(mm/dd/yyyy) Tax I.D. Number
%
Address: Street City State Zip Code
Email Address Telephone Number Relationship to Owner
PRIMARY or CONTINGENT Beneficiary’s Full Name/Entity Name Date of Birth Social Security/ Percentage
(mm/dd/yyyy) Tax I.D. Number
%
Address: Street City State Zip Code
Email Address Telephone Number Relationship to Owner
PRIMARY or CONTINGENT Beneficiary’s Full Name/Entity Name Date of Birth Social Security/ Percentage
(mm/dd/yyyy) Tax I.D. Number
%
Address: Street City State Zip Code
Email Address Telephone Number Relationship to Owner
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Uniform Transfers/Gifts to Minors (UTMA/UGMA)—Complete for a Beneficiary who is a minor.
Custodian Name, Address & Telephone Number
Name of Minor State Where UTMA/UGMA Was
Established
Custodian Name, Address & Telephone Number
Name of Minor State Where UTMA/UGMA Was
Established
8. ANNUITY PREMIUM PAYMENT AMOUNT
Premium Payment Amount: $
If paying by check, make payable to NYLIAC. Indicate total estimated amount including cash with application and anticipated transfer/exchange amount.
9. ANNUITY POLICY TYPE
No
Non-Qualified Is this a 1035 Exchange? Yes
Traditional IRA
Current Year Contribution Prior Year Contribution Transfer Rollover
Roth IRA
$ Year $ Year $
SEP IRA
Transfer Amount
Inherited IRA* $
*Not available for Joint Life policies.
Note: If this is a Traditional IRA, Roth IRA, or SEP IRA transfer/rollover, submit Qualified Transfer/Direct Rollover Form. If this is an Inherited IRA submit Inherited IRA Information/Transfer Form.
10. ADDITIONAL INFORMATION
Attach a separate sheet if additional space is needed.
11. FRAUD AND DISCLOSURE STATEMENTS
Please read the following carefully.
Any FRAUD person WARNING who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.
PARTIAL WITHDRAWALS
For purposes of calculating the guaranteed amount provided by the return of premium death benefit under the Policy, Partial Withdrawals (including required minimum distributions) reduce that guaranteed amount proportionally. In addition, any amount withdrawn from a Segment in the Index-Linked Account will not be included in the calculation of the Index-Linked Credit on the Segment Maturity Date.
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12. SIGNATURES, ACKNOWLEDGEMENTS AND TAX CERTIFICATION
Read statements and sign below
By signing below, I/We acknowledge and agree that: (1) All of the answers to questions and statements made in this application, which includes it is issued the while Premium the Allocation Owner(s) Form, and Annuitant(s) are true to the are best living. of my/our knowledge and belief. (2) This Policy will not become effective unless
(3) Unless otherwise indicated, the Owner of this Policy is the Applicant. (4) Under penalties of perjury, the Social Security/Taxpayer Identification Numbers provided on this application are certified to be correct. (5) No Agent/Registered Representative is authorized to accept risks, make or change this application or change any policy issued by the Company, not or give guaranteed up any of as the to Owner’s a fixed rights dollar or amount. requirements. Benefits based on the performance of the Separate Account are variable and are
The Owner’s tax certification provided below does not apply if the Owner is not a U.S. person (including a U.S. resident alien) and has otherwise completed and executed an applicable IRS Form W-8.
Owner Tax Certification:
Under (1) penalties of perjury, I (as Owner named) certify:
(2) My Social Security Number or Tax ID Number shown on this application is my correct taxpayer identification number, the I am IRS not that subject I am to subject backup to withholding backup withholding because: as (a) a Iresult am exempt of a failure from to backup report withholding; all interest or or dividend (b) I have income; not been or notified (c) the IRS by (3) has notified me that I am no longer subject to backup withholding, (4) I am a U.S. person (includes a U.S. resident alien), and The FATCA Foreign reporting Account is correct. Tax Compliance (Please note: Act if (FATCA) being submitted code entered for a on U. S. this Policy, form this (if any) last indicating certification that (4) I am does exempt not apply) from.
Check this box if the IRS has notified you that you are subject to backup withholding. If I am a U.S. entity, I am submitting a completed IRS Form W-9. my If I am foreign not a status U.S. citizen, and, if U. applicable, S. resident claim alien treaty or other benefits. U.S. person, I am submitting the applicable IRS Form W-8 with this form to certify The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
(City/State) Signed at SIGNED DATE
Owner’s Signature Joint Owner’s Signature (if applicable)
Annuitant’s Signature (if other than Owner) Joint Annuitant’s Signature (if applicable)
Applicant’s Signature (if other than Owner or Joint Owner) Applicant’s Printed Name
Agent’s/Registered Representative’s Signature Agent’s/Registered Representative’s Printed Name
Agent’s/Registered Representative’s Telephone Number State/License Number
General Office Name/Number Lic. Countersignature Resident Agent’s/Registered and Code Representative’s “Date Received” Stamp Here
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