First Golden American Life Insurance Company of New York Deferred Combination Variable and Fixed Annuity Application

Contract Categories: Business Finance › Subscription Agreements
Summary

This application is for individuals seeking a deferred combination variable and fixed annuity contract from First Golden American Life Insurance Company of New York. The applicant provides personal information, selects beneficiaries, chooses investment allocations, and designates death benefit options. The contract's value may fluctuate based on investment performance, and no minimum value is guaranteed. The application also addresses tax-qualified plans and potential replacement of existing policies. By signing, applicants acknowledge receipt of the prospectus and agree to the terms outlined.

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EX-4.S 25 idcvfaao.txt APPLICATION (OLD) FIRST GOLDEN AMERICAN FLEXIBLE PREMIUM LIFE INSURANCE COMPANY OF NEW YORK DEFERRED COMBINATION VARIABLE AND FIXED ANNUITY APPLICATION FIRST GOLDEN AMERICAN LIFE INSURANCE COMPANY OF NEW YORK IS A STOCK COMPANY DOMICILED IN NEW YORK, NEW YORK - --------------------------------------------------------------------------- 1. OWNER(S) - --------------------------------------------------------------------------- Name Male Female Soc. Sec. # or Tax ID.# / / / / - --------------------------------------------------------------------------- Permanent Address Phone ( ) - --------------------------------------------------------------------------- City State Zip Date of Birth - --------------------------------------------------------------------------- 2. ANNUITANT (IF OTHER THAN OWNER) - --------------------------------------------------------------------------- Name Male Female Soc. Sec. # or Tax ID.# / / / / - --------------------------------------------------------------------------- Permanent Address Phone ( ) - --------------------------------------------------------------------------- City State Zip Date of Birth Relation to Owner =========================================================================== CONTINGENT ANNUITANT (OPTIONAL) - --------------------------------------------------------------------------- Name Address Relation to Owner - --------------------------------------------------------------------------- 3. PRIMARY BENEFICIARY(IES) (IF MORE THAN ONE - INDICATE %) - --------------------------------------------------------------------------- Name(s) Relation to Owner - --------------------------------------------------------------------------- CONTINGENT BENEFICIARY(IES) Name Relation to Owner - --------------------------------------------------------------------------- 4. PLAN - --------------------------------------------------------------------------- / / DVA PLUS - --------------------------------------------------------------------------- 5. DEATH BENEFIT OPTIONS - --------------------------------------------------------------------------- / / Annual Ratchet / / Standard - --------------------------------------------------------------------------- 6. INITIAL PREMIUM AND ALLOCATION INFORMATION - --------------------------------------------------------------------------- (A) INITIAL PREMIUM PAID $__________ MAKE CHECK PAYABLE TO FIRST GOLDEN AMERICAN LIFE INSURANCE COMPANY OF NEW YORK Fill in percentages for premium allocation below (see INITIAL) (B) CHARGE DEDUCTION DIVISION: Optional. Please check box to elect. / /
ACCOUNT DIVISION INVESTMENT ADVISER (A) INITIAL RESEARCH MASSACHUSETTS FINANCIAL SERVICES % COMPANY (MFS) MID-CAP GROWTH MASSACHUSETTS FINANCIAL SERVICES % COMPANY (MFS) TOTAL RETURN MASSACHUSETTS FINANCIAL SERVICES % COMPANY (MFS) SMALL CAP FRED ALGER MANAGEMENT, INC. % GROWTH & INCOME ALLIANCE CAPITAL MANAGEMENT L.P. % GROWTH JANUS CAPITAL CORPORATION % FULLY MANAGED T. ROWE PRICE ASSOCIATES INC. % STRATEGIC EQUITY AIM CAPITAL MANAGEMENT, INC. % EQUITY INCOME T. ROWE PRICE ASSOCIATES INC. % RISING DIVIDENDS KAYNE, ANDERSON INV. MGMT., L.P. % CAPITAL APPRECIATION AIM CAPITAL MANAGEMENT, INC. % VAlUE EQUITY EAGLE ASSET MANAGEMENT, INC. % MANAGED GLOBAL PUTNAM INVESTMENT MANAGEMENT, INC. % EMERGING MARKETS PUTNAM INVESTMENT MANAGEMENT, INC. % HARD ASSETS BARING INTERNATIONAL INVESTMENT LIMITED % REAL ESTATE EII REALTY SECURITIES, INC. % LIMITED MATURITY BOND ING INVESTMENT MANAGEMENT, LLC % LIQUID ASSET ING INVESTMENT MANAGEMENT, LLC % GLOBAL FIXED INCOME BARING INTERNATIONAL INVESTMENT LIMITED % DEVELOPING WORLD BARING INTERNATIONAL INVESTMENT LIMITED % FIXED ALLOCATION ELECTION 1-YEAR % FIXED ALLOCATION ELECTION 3-YEAR % FIXED ALLOCATION ELECTION 5-YEAR % FIXED ALLOCATION ELECTION 7-YEAR % FIXED ALLOCATION ELECTION 10-YEAR % TOTAL 100%
First Golden American Life Insurance Company of New York, Variable Products Service Center, P.O. Box 11520, Church Street Station, New York, NY 10286-1520 ###-###-#### FG-AA-1000-12/95 - --------------------------------------------------------------------------- 7. OPTIONAL SYSTEMATIC PARTIAL WITHDRAWALS - --------------------------------------------------------------------------- If you want to receive Systematic Partial Withdrawals, your request must be received in writing. For the appropriate form, please call our Customer Service Center: 1 ###-###-####. - --------------------------------------------------------------------------- 8. TAX-QUALIFIED PLANS If you are funding a qualified plan, please specify type. - --------------------------------------------------------------------------- / / IRA / / IRA Rollover / / SEP/IRA / / Other ________________________ - --------------------------------------------------------------------------- 9. REPLACEMENT - --------------------------------------------------------------------------- Will the coverage applied for replace any existing annuity or life insurance policies on the annuitant's life? / / Yes (If yes, please complete following) / / No - --------------------------------------------------------------------------- Company Name Policy Number Face Amount - --------------------------------------------------------------------------- - --------------------------------------------------------------------------- 10. READ THE FOLLOWING STATEMENTS CAREFULLY AND SIGN BELOW: - BY SIGNING BELOW, I ACKNOWLEDGE RECEIPT OF THE PROSPECTUS. I UNDERSTAND THAT THIS CONTRACT'S CASH SURRENDER VALUE, 1) WHEN BASED ON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT DIVISION, MAY INCREASE OR DECREASE ON ANY DAY AND THAT NO MINIMUM VALUE IS GUARANTEED, AND 2) WHEN, BASED ON THE FIXED ACCOUNT, MAY BE SUBJECT TO A MARKET VALUE ADJUSTMENT, THE OPERATION OF WHICH MAY CAUSE THE VALUES TO INCREASE OR DECREASE. THIS CONTRACT IS IN ACCORD WITH MY ANTICIPATED FINANCIAL NEEDS. - I AGREE THAT, TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL STATEMENTS AND ANSWERS IN THIS APPLICATION ARE COMPLETE AND TRUE AND MAY BE RELIED UPON IN DETERMINING WHETHER TO ISSUE THE CONTRACT. MY ANSWERS WILL FORM A PART OF ANY CONTRACT TO BE ISSUED, AND ONLY THE OWNER AND FIRST GOLDEN AMERICAN HAVE THE AUTHORITY TO MODIFY THIS APPLICATION. - CONTRACTS AND POLICIES AND UNDERLYING SERIES SHARES OR SECURITIES WHICH FUND CONTRACTS AND POLICIES ARE NOT INSURED BY THE FDIC OR ANY OTHER AGENCY. THEY ARE NOT DEPOSITS OR OTHER OBLIGATIONS OF ANY BANK AND ARE NOT BANK GUARANTEED. ALSO, THEY ARE SUBJECT TO MARKET FLUCTUATION, INVESTMENT RISK AND POSSIBLE LOSS OF PRINCIPAL INVESTED. ______________________________________ _____________________________ Signature of Owner Signed at (City, State) Date ______________________________________ _____________________________ Signature of Joint Owner (if applicable) Signed at (City, State) Date ______________________________________ _____________________________ Signature of Annuitant (if other than Signed at (City, State) Date owner) Client Account No. (if applicable)_____________________ - --------------------------------------------------------------------------- FOR AGENT USE ONLY - --------------------------------------------------------------------------- DO YOU HAVE REASON TO BELIEVE THAT THE COVERAGE APPLIED FOR WILL REPLACE ANY EXISTING ANNUITY OR LIFE INSURANCE ON THE ANNUITANT'S LIFE? / / YES / / NO __________________________ ________________________ ___________________ Agent Signature Print Agent Name & No. Social Security No. __________________________________ Broker/Dealer/Branch - --------------------------------------------------------------------------- - --------------------------------------------------------------------------- Amendment to Application - --------------------------------------------------------------------------- - --------------------------------------------------------------------------- - --------------------------------------------------------------------------- - --------------------------------------------------------------------------- First Golden American Life Insurance Company of New York, Variable Products Service Center, P.O. Box 11520, Church Street Station, New York, NY 10286-1520 ###-###-#### FG-AA-1000-12/95