CHANGE OF BENEFICIARY

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1 CHANGE OF BENEFICIARY Instructions and Examples of Beneficiary Designations Change Of Beneficiary Request Form Provisions Relating To Beneficiary Designation, and Notice Regarding Testamentary Trust Page 2 Page 3 & 4 Page 5 This section for Agent s/representative s use only: TO SERVICE CENTER: SUBMITTED ON: G.O. NAME AND CODE: AGENT/REG. REP. NAME: Check if the applicable form is attached: Form 20885, Statement of Trust, must be attached if naming a trust as beneficiary. RETURN FORM TO: For Variable Life and Variable Annuity policies: New York Life, Variable Products Service Center Madison Square Station, PO Box 922, New York, NY For all other policies: If You Live In: AL, CT, DC, DE, FL, GA, IL, IN, KY, MA, ME, MD, MI, MS, NC, NH, NJ, NY, OH, PA, RI, SC, TN, VA, VT, WI, or WV, return this form to: New York Life, Cleveland Service Center PO Box 6916, Cleveland, OH If You Live In: AK, AR, AZ, CA, CO, HI, IA, ID, KS, LA, MN, MO, MT, NE, ND, NM, NV,OK, OR, SD, TX, UT, WA, or WY, return this form to: New York Life, Dallas Service Center PO Box , Dallas, TX Other: (i.e. foreign address, etc) return form to either location above (9/11) Page 1 of 5

2 INSTRUCTIONS FOR BENEFICIARY DESIGNATION Review the examples of beneficiary designations shown below and read page 5 BEFORE completing this form The policy should not be sent to the Company. An endorsement or notice will be returned to the Policyowner to be kept with the policy after the change has been recorded. If all changes do not fit on the Change of Beneficiary Request form, attach a page with your additional changes to the form. This page should contain the policy numbers affected as well as your signature. The beneficiary(ies) Social Security Number and Date of Birth will only be used if we cannot locate the beneficiary using any other manner. In the event of a discrepancy, the beneficiary's name and relationship will take precedence over the Social Security Number and Date of Birth provided. All designations are understood to be shared equally among all beneficiaries (within the same class) unless you designate otherwise on this form. DO NOT use this form if policy proceeds are to be paid under an optional method of payment or settlement. Contact your agent or one of our customer service representatives for details. DO NOT use the wording and/or when designating desired beneficiary. DO NOT use this form to change the beneficiary designation of any Joint Life or Dualife life insurance policies. Contact us and ask us to prepare the appropriate form for these cases. EXAMPLES OF BENEFICIARY DESIGNATIONS The phrase Insured/Annuitant or Policyowner when used below means: a) the Insured under a life insurance policy; b) the Annuitant or Policyowner under an annuity policy. It is usually desirable to name a contingent beneficiary or indicate how proceeds should be distributed in the event that the named beneficiary predeceases a) the Insured (if life policy) b) the Annuitant or Policyowner (if annuity policy). Insured s/annuitant s or Policyowner s Estate: First Beneficiary - The Insured s Estate. (Use if a life policy.) First Beneficiary - The Policyowner s Estate or Annuitant s Estate in accordance with the policy. (Use if an annuity policy.) First Beneficiary (only one first beneficiary): First beneficiaries (first beneficiaries in fractional shares or percentages. Contingent beneficiary named for each first beneficiary share) First Beneficiary - 50% or 1/2 to Mary A. Smith, wife of the Insured, if living, otherwise to John and Mary Smith, children of the Insured. First Beneficiary - 25% or 1/4 to Betty Smith, sister of the Insured, if living, otherwise to Henry Smith, brother of the Insured. First Beneficiaries (two or more first beneficiaries): First Beneficiary - 25% or 1/4 Henry Smith, brother of the Insured, if living, First Beneficiary - John B. Smith and Mary A. Smith, parents. First, Second and Third Beneficiary (one first, one second and one third otherwise to Betty Smith, sister of the Insured. First and Second beneficiaries (first beneficiaries in fractional shares or beneficiary): percentages. Second beneficiaries are not in fractional shares.) First Beneficiaries - 60% or 3/5 to Mary A. Smith, wife of the Insured, Second Beneficiary - Joan D. Smith, daughter. 40% or 2/5 to John and Mary Smith, children of the Insured. Third Beneficiary - Elizabeth F. Smith, mother. Second Beneficiaries - Betty Scott, sister of the Insured and Henry Smith, brother of First Beneficiary and Second Beneficiaries (one first and two or more second the Insured. beneficiaries): First beneficiaries (first beneficiaries in fractional shares or percentages, no second beneficiary) Second Beneficiary - Joan D. Smith and Richard C. Smith, children. First Beneficiaries - 50% or 1/2 to Mary A. Smith, wife of the Insured, First Beneficiary; Second Beneficiaries are the children born of the marriage of the Insured/Annuitant or Policyowner and her present husband: 25% or 1/4 to Betty Smith, sister of the Insured, 25% or 1/4 to Henry Smith, brother of the Insured. First Beneficiary - James A. Smith, husband. * Second Beneficiary - children born of marriage to James A. Smith. First Beneficiaries are the children born of marriage of the Insured s/annuitant s or Policyowner s present marriage: * First Beneficiary - children born of marriage to Mary A. Smith. * If the beneficiary designation is to include adopted children, insert and any children legally adopted by the Insured/Annuitant or Policyowner after children born of marriage to James A. (Mary A.) Smith. First Beneficiary, Second Beneficiary, Third Beneficiary is the children of the Second Beneficiary - Jane F. Doe, sister. Third Beneficiary - children of Jane F. Doe, sister. First Beneficiary, two or more Second Beneficiaries where the interest of any deceased Second Beneficiary is to pass to his or her children, if any, and if no such children, to the survivors or survivor of said Second Beneficiaries. (This type of designation is also known as per stirpes): First Beneficiary - James B. Smith, husband. Second Beneficiary - John B. Smith and Eileen H. Smith, children. Any interest which a deceased second beneficiary would, if living, have had in policy proceeds shall be shared equally by any living children of that beneficiary. Uniform Transfers to Minors Act (UTMA) or Uniform Gift to Minors Act (UGMA) (insert name of the custodian) as Custodian for (insert name of the minor and relationship to insured) under the (insert the state in which the minor lives) Uniform Transfers (or Gifts) to Minors Act: First Beneficiary is the Trustee of a Living Trust: First Beneficiary - John Smith, as Trustee under Trust ABC Dated. NOTE: Completed and signed Form 20885, Statement of Trust, must accompany this request. Testamentary Trustee under Last Will and Testament of Insured/Annuitant: First Beneficiary - Mary A. Smith wife. Second Beneficiary - Testamentary Trust under last will and testament of the Insured/Annuitant. Testamentary Trustee under Last Will and Testament of Policyowner, if the Policyowner is other than the Insured/Annuitant: First Beneficiary Policyowner. Second Beneficiary - Testamentary Trust under last will and testament of the Policyowner. NOTE: You can always have named beneficiaries classed before and/or after the Testamentary Trust. See NOTICE REGARDING TESTAMENTARY TRUST UNDER LAST WILL AND TESTAMENT on page 5 of this form (9/11) Page 2 of 5

3 NEW YORK LIFE INSURANCE COMPANY NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION (A Delaware Corp.) NYLIFE INSURANCE COMPANY OF ARIZONA (Not licensed in every state) CHANGE OF BENEFICIARY REQUEST Office Received Stamp Please print clearly in ink. (See pages 2 and 5 before completing this form.) Policy Number(s) Insured/Annuitant Other Insured (only applies to Survivorship Life plans) Enter Beneficiaries Full Name, Residence Address, Telephone Number, Social Security Number, Date of Birth & Relationship to the Insured(s) (if Life plan) or to the Policyowner (if Annuity plan). See Instructions on Page 2 for an explanation of why we request the Beneficiary s Social Security Number and Date of Birth. IMPORTANT NOTES: DESIGNATIONS WITH SPECIFIC DOLLAR AMOUNTS ARE NOT AVAILABLE. SECTION I IF NAMING A CUSTODIAN FOR A MINOR BENEFICIARY, THE TERM UTMA/UGMA AND THE MINOR S STATE OF RESIDENCE MUST BE PRESENT IN THE BENEFICIARY DESIGNATION SECTION(S). SEE PAGE 2 FOR INSTRUCTIONS. Unless specified in Section III, this change of beneficiary will be effective for all coverage in my name under this policy. For proceeds payable because of the death of: 1) the Insured(s) under a Life plan or 2) the first insured covered under a New York Life Family Protection policy; or 3) the Annuitant or Policyowner under an Annuity plan, unless specified otherwise in the policy. SECTION II For proceeds payable because of the death of: 1) the second insured covered under a New York Life Family Protection policy; or 2) the Spouse covered under an SCI rider or Family life insurance policy (9/11) Page 3 of 5

4 SECTION III - For proceeds payable under life insurance because of the death of: a) A Child covered under an SCI, CI rider, or Family Insurance policy b) covered under the: Other Covered Insured Rider (O.C.I) 5 Yr. Term Rider 7 Yr. Term Rider c) For the first insured covered under a First-to-Die Rider under the: Increasing Term Rider (ITR) on a Survivorship Whole Life (SWL) policy Level Term First-To-Die Rider (LFD) on a Survivorship Whole Life (SWL) policy Level Term First-To-Die Rider (LFD) on a Survivorship Variable Universal Life (SVUL) policy d) Any child covered under a New York Life Family Protection policy I understand and agree that the PROVISIONS RELATING TO BENEFICIARY DESIGNATION and, if applicable, the NOTICE REGARDING TESTAMENTARY TRUST UNDER LAST WILL AND TESTAMENT, on page 5 of this form are made a part of the above beneficiary designation. Beneficiary changes to all life and variable annuity policies where the Policyowner resides in MASSACHUSETTS require the signature of a witness below. The witness can be anyone over the age of 18 who is not the Insured, Annuitant, Policyowner or designated beneficiary. X / / X / / SIGNATURE OF POLICYOWNER DATE ADDITIONAL SIGNATURE, IF REQUIRED DATE ( ) Policyowner s Telephone number If the indicated policy is corporate owned then two Officer s Signatures must be provided as well as their respective Titles X X SIGNATURE OF OFFICER OFFICER S TITLE SIGNATURE OF OFFICER OFFICER S TITLE (9/11) Page 4 of 5

5 PROVISIONS RELATING TO THE BENEFICIARY DESIGNATION Naming of Beneficiary and Death of Beneficiary: Unless otherwise provided in the policy, or in the beneficiary designation on page 3 of this form, the following provisions shall apply: The words we, us or our refer to New York Life Insurance Company and its affiliated companies. The phrase Insured/Annuitant or Policyowner when used below means: a) the Insured under a life insurance policy; b) the Annuitant or Policyowner under an annuity policy. 1. Beneficiaries (or payees) may be classed as first, second, and so on. Surviving beneficiaries in the same class will have an equal share in the proceeds, or in any periodic income payments payable from these proceeds, unless the shares are otherwise stated. The stated shares of life insurance or annuity death benefit proceeds will be paid first to any surviving first beneficiaries. If no first beneficiaries survive, payment will be made to any surviving second beneficiaries, and so on. 2. If no beneficiary for any life insurance or death benefit proceeds survives, the right to those proceeds will pass to the Policyowner. If the Policyowner was the Insured/Annuitant the right to those proceeds will pass to the Policyowner s estate. If any beneficiary dies at the same time as the Insured/Annuitant or Policyowner or if the policy so provides, within 15 days after such date, but before proof of the Insured s/annuitant s or Policyowner s death is received by us, the proceeds will be paid as though that beneficiary died first. Change of Beneficiary: The person having the right to change a beneficiary can do so while the Insured or Annuitant is living by using this signed notice and furnishing the necessary information to us. When we record the change, it will take effect as of the date stated in your policy, subject to any payment made or other action taken by us before recording it. This change of beneficiary will revoke any existing beneficiary designation. Provision under a Deferred Annuity when the Spouse is named Beneficiary: If the Policyowner s spouse is named the sole first beneficiary and the Policyowner dies, the policy may be continued with the surviving spouse as the new owner, if so provided in the policy. If the Policyowner was also the Annuitant, the surviving spouse will also become the new Annuitant. If the surviving spouse chooses to continue the policy, no death benefit will be paid as a consequence of the death of the first spouse. NOTICE REGARDING TESTAMENTARY TRUST UNDER LAST WILL AND TESTAMENT The following is understood and agreed when naming a Testamentary Trust under a Last Will and Testament as the beneficiary of a policy issued by us: If the Insured/Annuitant or Policyowner dies with a Last Will and Testament, and (1) it does not create a Trust and name a Trustee, or (2), if within 12 months (18 months in Mississippi, New York, and Texas; 6 months in Florida and North Carolina) after the Insured s/annuitant s or Policyowner s death, no court proceeding has been started to probate the Last Will and Testament or no Trustee qualifies and claims the proceeds, then the proceeds shall be paid to the named contingent beneficiary. If the named contingent beneficiary is not living, and no further beneficiary is named, then payment shall be made to the Policyowner. If the Policyowner was the Insured/Annuitant, the right to those proceeds will pass to the Policyowner s estate. If the Insured/Annuitant or Policyowner dies intestate (without a Last Will and Testament), then the proceeds shall be paid to the named contingent beneficiary. If the named contingent beneficiary is not living, and no further contingent beneficiary is named, then payment shall be made to the Policyowner. If the Policyowner was the Insured/Annuitant, the right to those proceeds will pass to the Policyowner s estate. We are not obligated to inquire about the terms of any Trust affecting this policy or its proceeds and shall not be held responsible for knowing the terms of any such Trust. Payment to and receipt by said Trustee(s) or any successor Trustee(s), or payment to and receipt by the contingent beneficiary or Policyowner s estate shall constitute as full discharge and releases us to the extent of such payment. The full discharge and release of our obligation for payment applies to all persons and fiduciaries having any interest in such proceeds (9/11) Page 5 of 5

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