Insurance Policy NYLife

INSURANCE POLICY — NYLife

Policy Identification

Policy Number:    Effective Date:    Expiration Date:

Insured / Applicant Information

Date of Birth:    Place of Birth:    Tax ID / SSN:

Policy Details

Policy Form:    Face Amount / Coverage: $    Deductible (if applicable): $

Premium Amount: $    Premium Mode: Monthly Quarterly Annual

Grace Period:    Reinstatement Period:

Coverages and Riders (select applicable)

Basic Death Benefit     Accidental Death Benefit     Waiver of Premium

Critical Illness Rider     Long-Term Care Rider     Disability Income Rider

Exclusions and Limitations

This policy does not provide coverage for loss or liability arising directly or indirectly from: (a) intentionally self-inflicted injury or suicide within the initial contestable period; (b) acts of war or declared hostilities; (c) participation in felonious or illegal acts; (d) material misrepresentation or fraud by the insured; or (e) aviation activities except as a fare-paying passenger on a scheduled commercial flight. Any exclusion specifically listed in an attached endorsement controls.

Beneficiary Designation

Primary Beneficiary 1:

Relationship:   Allocation %:

Primary Beneficiary 2:

Relationship:   Allocation %:

Contingent Beneficiary 1:

Relationship:   Allocation %:

Claims and Notice of Loss

Upon loss or event giving rise to a claim under this policy, the claimant must provide written notice to the company within a reasonable time. The claimant shall furnish such proof of loss, medical records, and other documentation as the company reasonably requests. Failure to provide timely notice or required documentation may result in denial of benefits where prejudice results.

Death Certificate     Medical Records     Police Report     Proof of Identity

Policy Provisions and Legal Terms

Incontestability: Except for non-payment of premium and fraud in the procurement of this policy, this policy shall be incontestable after it has been in force during the lifetime of the insured for the contestable period specified in the policy form. Any material misstatements made by the insured in the application may render coverage voidable as permitted by law.

Suicide: If the insured dies by suicide within the suicide period specified in the policy form, the company shall have the right to deny the death benefit and limit recovery to the premiums paid, less any indebtedness, subject to applicable statutes.

Assignment: The owner may assign this policy subject to any rights of the company to require written notice of assignment. The company is not responsible for the validity or sufficiency of any assignment.

Change of Beneficiary: The owner may change the beneficiary designation as provided by the policy form, subject to any irrevocable beneficiary designation and applicable law.

Governing Law and Venue: This policy shall be governed by the laws of the state specified in the policy provisions. Any dispute arising under this policy shall be resolved in the courts or by arbitration as provided in the policy form.

Declarations and Applicant Certification

By signing below, I declare that the statements and answers contained in the application and on this policy are true and complete to the best of my knowledge and belief. I understand that any false statement or material misrepresentation may be grounds for contesting coverage or rescission to the extent permitted by law. I authorize the release of medical and other information to the company for the purpose of underwriting, policy administration and claims adjudication.

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