NewYork Regulation 60 Forms Booklet

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1 Allstate Life Insurance Company of New York EXPRESS MAIL: 2940 S. 84th Street Lincoln, NE Attn: Reg 60 Unit STANDARD MAIL: P.O. Box Lincoln, NE Phone: Fax: NewYork Regulation 60 Forms Booklet New York Regulation 60 Instructions and Checklist Appendix 11 - Definition of Replacement Request for Replacement Information (Transmittal / Authorization Form) Product Description and Good Faith Quote Information FIC121FIDNY (05/08)

2 New York Regulation 60 INSTRUCTIONS AND CHECKLIST IMPORTANT: Retainacopyofall forms for your records Allstate Life Insurance Company of New York Express Mail: 2940 S. 84th Street, Lincoln, NE Attn: Reg 60 Unit Standard Mail: P.O. Box 82656, Lincoln, NE Phone: Fax: PART 1 Complete enclosed Appendix 11 Definition of Replacement : This form MUST be completed and included for each proposed sale. After completing Appendix 11, please perform ONE of the following: PART 2 A. Non-Replacement - If ALL of the six questions in the Appendix 11 form are answered NO, a replacement IS NOT involved; however, the completed Appendix 11 form is still required to be sent in with the application. B. Replacement -IfANY of the six questions in the Appendix 11 form are answered YES, a replacement IS involved and the following additional forms are required to be sent in with the completed Appendix 11 form: A completed Request for Replacement Information (Transmittal / Authorization) form (included in this booklet) A completed Product Description and Good Faith Quote Information form (Included in this booklet) A copy of the customer s most recent quarterly/annual statement if available For life insurance products, please include the appropriate sales illustration After Allstate receives the required forms, Allstate will complete and send a Disclosure Statement to the surrendering company. The surrendering company has 20 days from the date of receipt to return the Disclosure Statement information to Allstate. After Allstate receives it from the surrendering company, Allstate will forward the Disclosure Statement information to you at which point you will proceed to Part 2 below. Send all required forms to Allstate Life Insurance Company of New York at the above address. Express overnight mail is recommended. Complete Disclosure Statement information: For Annuity to Annuity replacements: Appendix 10B: Complete Agent s Statement and Remarks and review form with customer. For Life to Life or Life to Annuity replacements: Appendix 10A: Complete Agent s Statement and Remarks and review form with customer. Include all supporting data used to complete the Disclosure Statement (e.g., information received from replaced insurer or all back-up materials used for good faith estimates) Include any sales illustrations and sales materials used in the sale or to complete the Disclosure Statement. For life insurance only, provide certification if no illustration was used. Complete Appendix 10C Important Notice Regarding Replacement or Change of Life Insurance Policies or Annuity Contracts. Complete Application for Annuity or Application for Life Insurance - must be signed and dated after Appendix 11. For transactions involving 1035 Exchange or Transfer of Qualified Funds: Include appropriate 1035 Exchange form or Transfer/Rollover of Qualified Funds form Send all required forms to Allstate Life Insurance Company of New York at the above address. Express overnight mail is recommended. FIC121CNY (05/08)

3 APPENDIX 11 INSURANCE DEPARTMENT OF THE STATE OF NEW YORK DEFINITION OF REPLACEMENT IN ORDER TO DETERMINE WHETHER YOU ARE REPLACING OR OTHERWISE CHANGING THE STATUS OF EXIST- ING LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS, AND IN ORDER TO RECEIVE THE VALUABLE INFORMA- TION NECESSARY TO MAKE A CAREFUL COMPARISON IF YOU ARE CONTEMPLATING REPLACEMENT, THE AGENT OR BROKER IS REQUIRED TO ASK YOU THE FOLLOWING QUESTIONS AND EXPLAIN ANY ITEMS THAT YOU DO NOT UNDERSTAND. AS PART OF YOUR PURCHASE OF A NEW LIFE INSURANCE POLICY OR A NEW ANNUITY CONTRACT, HAS EXIST- ING COVERAGE BEEN, OR IS IT LIKELY TO BE: (1) LAPSED, SURRENDERED, PARTIALLY SURRENDERED, FORFEITED, ASSIGNED TO THE INSURER REPLACING THE LIFE INSURANCE POLICY OR ANNUITY CONTRACT, OR OTHERWISE TERMINATED? (2) CHANGED OR MODIFIED INTO PAID-UP INSURANCE; CONTINUED AS EXTENDED TERM INSURANCE OR UNDER ANOTHER FORM OF NONFORFEITURE BENEFIT; OR OTHERWISE REDUCED IN VALUE BY THE USE OF NONFORFEITURE BENEFITS, DIVIDEND ACCUMULATIONS, DIVIDEND CASH VALUES OR OTHER CASH VAL- UES? (3) CHANGED OR MODIFIED SO AS TO EFFECT A REDUCTION EITHER IN THE AMOUNT OF THE EXISTING LIFE INSURANCE OR ANNUITY BENEFIT OR IN THE PERIOD OF TIME THE EXISTING LIFE INSURANCE OR ANNUITY BENEFIT WILL CONTINUE IN FORCE? (4) REISSUED WITH A REDUCTION IN AMOUNT SUCH THAT ANY CASH VALUES ARE RELEASED, INCLUDING ALL TRANSACTIONS WHEREIN AN AMOUNT OF DIVIDEND ACCUMULATIONS OR PAID-UP ADDITIONS IS TO BE RELEASED ON ONE OR MORE OF THE EXISTING POLICIES? (5) ASSIGNED AS COLLATERAL FOR A LOAN OR MADE SUBJECT TO BORROWING OR WITHDRAWAL OR ANY POR- TION OF THE LOAN VALUE, INCLUDING ALL TRANSACTIONS WHEREIN ANY AMOUNT OF DIVIDEND ACCUMULA- TIONS OR PAID-UP ADDITIONS IS TO BE BORROWED OR WITHDRAWN ON ONE OR MORE EXISTING POLICIES? (6) CONTINUED WITH A STOPPAGE OF PREMIUM PAYMENTS OR REDUCTION IN THE AMOUNT OF PREMIUM PAID? IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, A REPLACEMENT AS DEFINED BY NEW YORK INSURANCE DEPARTMENT REGULATION NO. 60 HAS OCCURRED OR IS LIKELY TO OCCUR AND YOUR AGENT OR BROKER IS REQUIRED TO PROVIDE YOU WITH A COMPLETED DISCLOSURE STATEMENT AND THE IMPORTANT NOTICE REGARDING REPLACEMENT OR CHANGE OF LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS. DATE SIGNATURE OF OWNER DATE SIGNATURE OF JOINT OWNER TO THE BEST OF MY KNOWLEDGE, A REPLACEMENT IS INVOLVED IN THIS TRANSACTION: DATE SIGNATURE OF AGENT OR BROKER NYLR (02/06)

4 REGULATION 60 REQUEST FOR REPLACEMENT INFORMATION (TRANSMITTAL / AUTHORIZATION) FORM A. REPLACED POLICY / CONTRACT INFORMATION REPLACED COMPANY NAME STREET ADDRESS ALLSTATE LIFE INSURANCE COMPANY OF NEW YORK Life and Annuity Processing Center - Attn: Reg 60 Unit Standard Mail: PO Box 82656, Lincoln, NE Express Mail: 2940 S. 84th Street, Lincoln NE FAX: CITY STATE ZIP 1ST POLICY / CONTRACT # TO BE REPLACED: 2ND POLICY / CONTRACT # TO BE REPLACED: 3RD POLICY / CONTRACT # TO BE REPLACED: Life Annuity Life Annuity Life Annuity Full Partial Amount: $ Qualified Non-Qualified Full Partial Amount: $ Qualified Non-Qualified Full Partial Amount: $ Qualified Non-Qualified Please see the authorization below to release information pursuant to New York Regulation 60. For your convenience, we have included a copy of the Disclosure Statement. Please complete the replaced company s portion of the attached Disclosure Statement and return it to us. If there are any questions, please contact us at : B. PROPOSED OWNER / APPLICANT INFORMATION PROPOSED OWNER/APPLICANT NAME JOINT OWNER (IF ANY) STREET ADDRESS PHONE CITY STATE ZIP PLEASE SEND THIS INFORMATION TO: Allstate Life Insurance Company of New York at the address listed at the top of this page AND Replacing Agent at the following address C. REPLACING AGENT INFORMATION REPLACING AGENT NAME FIRM STREET ADDRESS CITY STATE ZIP PHONE FAX AGENT NUMBER D. REQUIRED INFORMATION TO BE PROVIDED BY THE REPLACING AGENT: For life insurance policies, please include the proposed sales illustration. For annuity contracts, please complete and include Product Description and Good Faith Quote Information form If the customer is considering transferring money into an existing contract or policy, please provide the existing contract/policy number: # E. AUTHORIZATION: By signing below, I authorize and request the undersigned agent and Allstate Life Insurance Company of New York to obtain account information from my current insurer related to my existing life insurance policy or annuity contract. SIGNATURE OF OWNER/APPLICANT DATE SIGNATURE OF JOINT OWNER/APPLICANT DATE F. AGENT CERTIFICATION: To the best of my knowledge, a replacement is involved in this transaction. SIGNATURE OF AGENT PRINTED NAME OF AGENT DATE NYLR311-4 (01/07)

5 PRODUCT DESCRIPTION AND GOOD FAITH QUOTE INFORMATION Please include this page with your Regulation 60 request 1. GENERAL INFORMATION Advisor/Representative Name Allstate Life Insurance Company of New York Express Mail: 2940 S. 84th Street, Lincoln, NE Attn: Reg 60 Unit Standard Mail: P.O. Box 82656, Lincoln, NE Phone: Fax: Customer Name Firm Office Phone # Cell # (If Applicable) Fax # 2. PRODUCT INFORMATION Please check the box next to all applicable products and options below. Note: Products and options listed may not be available at all firms. ANNUITIES Preferred Performance Fixed Annuity: Selection 1 Selection 2 Return of Purchase Payment Guarantee: Yes (Accept) No (Waive) Please run quote both ways (with and w/o ROP) Guarantee Period(s) - Enter amount allocated to each: 1yr $ 3yr $ 5yr $ 6yr $ Allstate Treasury-Linked Annuity: Return of Purchase Payment Guarantee: Yes (Accept) No (Waive) Please run quote both ways (with and w/o ROP) ChoiceRate Annuity SM : Guarantee Period: 5 7 LIFE Generation Advantage - Single Premium UL: Illustration is included If no illustration is included, please supply the following: Rating: Standard Special Gender: M F Birthdate: 3. GOOD FAITH QUOTES Please provide the following information about the contract/policy being surrendered so that in the event requested information is not received from the transferring company within the applicable 20-day period, we may create a good faith quote. ANNUITY CONTRACTS: Contract Issue Date: Contract Value: Contract Surrender Charge (If known): Guaranteed Interest Rate (for Fixed Annuities): Current Interest Rate (for Fixed Annuities): LIFE POLICIES: Type of Insurance Policy (Term, Universal Life, Whole Life, etc.) Policy Issue Date: Policy Face Value: Annual Premium for next 10 Years: Guaranteed Interest Rate (If Applicable): Bar Code Here - For Home Office Use Only FIC121GFF FID (05/08)

6 FIC121FIDNY SKU# FIC121FIDNY (05/08)

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