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CHANGE OF BENEFICIARY Next Print CHANGE OF BENEFICIARY Instructions

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                                CHANGE OF BENEFICIARY
           Instructions and Examples of Beneficiary Designations    Page 2
           Change Of Beneficiary Request Form                       Page 3
           Provisions Relating To Beneficiary Designation, and      Page 4
            Notice Regarding Testamentary Trust




           This section for Agent’s/Representative’s use only:



           TO SERVICE CENTER:

           SUBMITTED ON:

           G.O. NAME AND CODE:

           AGENT/REG. REP. NAME:




 21131 (08/06)                                        Page 1 of 4
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                                          INSTRUCTIONS FOR BENEFICIARY DESIGNATION
                  Review the examples of beneficiary designations shown below and read page 4 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 will help us locate him or her if there is a future claim under this policy. It 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 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.
     NOTE – Designations with specific dollar amounts are not available.
                                                     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 beneficiaries (first beneficiaries in fractional shares. Contingent beneficiary
     First Beneficiary - The Insured’s Estate. (Use if a life policy.)                  named for each first beneficiary share)
     First Beneficiary - The Policyowner’s Estate or Annuitant’s Estate in
                                                                                        First Beneficiary - 50% to Mary A. Smith, wife of the Insured, if living, otherwise
     accordance with the policy. (Use if an annuity policy.)
                                                                                        to John and Mary Smith, children of the Insured.
     First Beneficiary (only one first beneficiary):
                                                                                        First Beneficiary - 25% to Betty Smith, sister of the Insured, if living, otherwise to
     First Beneficiary - Mary A. Smith, wife.
                                                                                        Henry Smith, brother of the Insured.
     First Beneficiaries (two or more first beneficiaries):
                                                                                        First Beneficiary - 25% Henry Smith, brother of the Insured, if living, otherwise to
     First Beneficiary - John B. Smith and Mary A. Smith, parents.
                                                                                        Betty Smith, sister of the Insured.
     First, Second and Third Beneficiary (one first, one second and one third
                                                                                        First and Second beneficiaries (first beneficiaries in fractional shares. Second
     beneficiary):                                                                      beneficiaries are not in fractional shares.)
     First Beneficiary - Mary A. Smith, wife.                                           First Beneficiaries - 60% to Mary A. Smith, wife of the Insured,
     Second Beneficiary - Joan D. Smith, daughter.                                      40% 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
     First Beneficiary and Second Beneficiaries (one first and two or more second       of the Insured.
     beneficiaries):
     First Beneficiary - Mary A. Smith, wife.                                           First beneficiaries (first beneficiaries in fractional shares, no second
     Second Beneficiary - Joan D. Smith and Richard C. Smith, children.                 beneficiary)
     First Beneficiary; Second Beneficiaries are the children born of the marriage      First Beneficiaries - 50% to Mary A. Smith, wife of the Insured,
     of the Insured/Annuitant or Policyowner and her present husband:                   25% to Betty Smith, sister of the Insured,
     First Beneficiary - James A. Smith, husband.                                       25% to Henry Smith, brother of the Insured.
     * Second Beneficiary - children born of marriage to James A. Smith.                _____________________________________________________________________________

     First Beneficiaries are the children born of marriage of the                       First Beneficiary is the Trustee of a Living Trust:
     Insured’s/Annuitant’s or Policyowner’s present marriage:                           First Beneficiary - John Smith, as Trustee under Trust ABC Dated __________.
     * First Beneficiary - children born of marriage to Mary A. Smith.                  NOTE: Completed and signed statement “A” of Form 20885 must accompany this
                                                                                        request.
     * If the beneficiary designation is to include adopted children, insert “and any
     children legally adopted by the Insured/Annuitant or Policyowner” after            Uniform Transfers to Minors Act (UTMA) or Uniform Gift to Minors Act
     “children born of marriage to James A. (Mary A.) Smith.”                           (UGMA):
                                                                                        If beneficiary is either of the designations shown above, completed and signed
     First Beneficiary, Second Beneficiary, Third Beneficiary is the children of the    form 17697 must accompany this request.
     Second Beneficiary:                                                                Testamentary Trustee under Last Will and Testament of Insured/Annuitant:
     First Beneficiary - Mary A. Smith, wife.                                           First Beneficiary - Mary A. Smith wife.
     Second Beneficiary - Jane F. Doe, sister.                                          Second Beneficiary - Testamentary Trust under last will and testament of the
     Third Beneficiary - children of Jane F. Doe, sister.                               Insured/Annuitant.
     First Beneficiary, two or more Second Beneficiaries where the interest of any      Testamentary Trustee under Last Will and Testament of Policyowner, if the
     deceased Second Beneficiary is to pass to his or her children, if any, and if no   Policyowner is other than the Insured/Annuitant:
     such children, to the survivors or survivor of said Second Beneficiaries. This     First Beneficiary – Policyowner.
     type of designation is also known as per stirpes):                                 Second Beneficiary - Testamentary Trust under last will and testament of the
     First Beneficiary - James B. Smith, husband.                                       Policyowner.
     Second Beneficiary - John B. Smith and Eileen H. Smith, children. Any interest     NOTE: You can always have named beneficiaries “classed” before and/or after the
     which a deceased second beneficiary would, if living, have had in policy           Testamentary Trust.
     proceeds shall be shared equally by any living children of that beneficiary.
                                                                                        See “NOTICE REGARDING TESTAMENTARY TRUST UNDER LAST
                                                                                        WILL AND TESTAMENT” on page 4 of this form.




 21131 (08/06)                                                           Page 2 of 4
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                     NEW YORK LIFE INSURANCE COMPANY                                                                                      Office Received Stamp

                     NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION (A Delaware Corp.)
                     NYLIFE INSURANCE COMPANY OF ARIZONA (Not licensed in every state)
                                                         CHANGE OF BENEFICIARY REQUEST
     Please print clearly in ink or use a typewriter. (See pages 2 and 4 before completing this form.)
     Policy Number(s)
     Insured/Annuitant
                                         (First Name,    Middle Name,    Last Name)
     Other Insured (only applies to Survivorship Life plans)
                                                                                      (First Name,    Middle Name,   Last Name)
     Enter Beneficiaries’ Full Name, Residence Address, Social Security Number & 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.
     SECTION I         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.
     First Beneficiary:


     Second Beneficiary:


     Third Beneficiary:


     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.
     First Beneficiary:


     Second Beneficiary:


     Third Beneficiary:


     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:
                          (First Name,    Middle Name,    Last Name)

                   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
     First Beneficiary:


     Second Beneficiary:

     Third Beneficiary:

      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 4 of this form are made a part of the above beneficiary designation.
      Beneficiary changes to all life and variable annuity policies issued 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

     X                                                                                               X
          SIGNATURE OF OFFICER                                         OFFICER’S TITLE               SIGNATURE OF OFFICER                            OFFICER’S TITLE
                 If the indicated policy is corporate owned then two Officer’s Signatures must be provided as well as their respective Titles
 21131 (08/06)                                                              Page 3 of 4
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         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.




 21131 (08/06)                                            Page 4 of 4

								
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