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IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR ANNU ITIES This document must be signed by the Applicant and the Producer, and a copy left with the Applicant. You are contemplating the purchase of a life insurance policy or annuity contrac t. In some cases the purchase may involve discontinuing or changing an existing policy or annuity contract. If so, a replacement is occurring. Fina nced purchases are also considered replacements. A replacement occurs when a new policy or annuity contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing policy or annuity contract, or an existing policy or annuity con tract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase. A financed purchase occurs when the purchase of a new life insurance policy invo lves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing policy, to pay all or part of any premium or payment due on the new policy. A financed purchase is a replacement. You should carefully consider whether a replacement is in your best interest. Yo u will pay acquisition costs and there may be surrender costs deducted from your policy or annuity contract. You may be able to make changes to your ex isting policy or annuity contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy and may reduce the amount paid upon the death of the insured. We want you to understand the effects of replacement before you make your purcha se decision and ask that you answer the following questions and consider the questions on the reverse side of this form. ? 1. Do you own any existing life insurance policies or annuity contracts? (If s , complete questions 2, 3 and 4 below. yes no If No , do not answer questions 2, 3 and 4.) ? 2. Are you considering discontinuing making premium payments, surrendering, fo rfeiting, assigning to the insurer, yes no or otherwise terminating your existing policy or annuity contract? ? 3. Are you considering using funds from your existing policies or annuity cont racts to pay premiums due on the new yes no policy or annuity contract? ? 4. Is the life insurance policy or annuity contract for which you are applying , to be the result of a 1035 exchange? yes no If you answered Yes to questions 2, 3, or 4, list each existing policy or annuity contract you are contemplating replacing. Also identify for each policy whether it will be replaced, used as a source of financing or replac ed in conjunction with a 1035 exchange. (If additional space is required, complete another form.) United Annuity Ye

United Ann Name of Insurance Company ______________________________________________ Policy or Annuity Contract #_____________ ? Marion L Wilmington III Replaced 1035 Exchange Name of Insured or Annuitant _____________________________________________ Financed United Annuity UA12345 Name of Insurance Company ______________________________________________ Policy or Annuity Contract #_____________ ? Marione L Wilmington III Replaced 1035 Exchange Name of Insured or Annuitant _____________________________________________ Financed United Annuity UA12345 Name of Insurance Company ______________________________________________ Policy or Annuity Contract #_____________ ? Eileen L Wilmington III Replaced 1035 Exchange Name of Insured or Annuitant _____________________________________________ Financed United Annuity UA12345 Name of Insurance Company ______________________________________________ Policy or Annuity Contract #_____________ ? Lilian L Wilmington III Replaced 1035 Exchange Name of Insured or Annuitant _____________________________________________ Financed Make sure you know the facts. Contact your existing company or its producer for information about the old policy or annuity contract. At your request, the existing insurer must send you an in-force illustration, polic y summary or available disclosure documents. Ask for and retain all sales material used by the producer in the sales presentation. Be sur e that you are making an informed decision. The existing policy(ies) or annuity contract(s) is/are being considered for repl acement because ____________________________________ Better company rating _______________________________________________________________________________ _______________________________ _______________________________________________________________________________ _______________________________ _______________________________________________________________________________

_______________________________ I do not want this notice read aloud to me. l only if they do not want the notice read aloud.) e: Applicant s Signature

(Applicant must initia

I certify that the responses herein are, to the best of my knowledge, accurat Applicant s Name (Printed) S t c a Massachusetts e m Matthew X X i v / / e p F d D F I Producer Acknowledgement: By reason of this transaction, is replacement invol ved? yes no H a C t Producer s Signature e e E Producer s Name (Printed) r R e X / 22190.100 0111:120111014957 ----------------------- Page 2----------------------/ X WILLIAM e E MAHONEY Date O A Sowmya Date

IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR A NNUITIES Important considerations if you are contemplating replacing your existing policy or annuity contract A replacement may not be in your best interest, or your decision could be a goo

d one. You should make a careful comparison of the costs and benefits of your existing policy or annuity contract and the proposed policy or annuity contract. One way to do this is to ask the company or producer that sold you your existing policy or annuity contract to provide you with information co ncerning your existing policy or annuity contract. This may include an illustration of how your existing policy or annuity contra ct is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to com pare policies or annuity contracts. You should discuss the following with your producer to determine whether replacement or financing your purchase makes sense: Premiums Policy Values Are they affordable? New policies usually take longer to build cash values and to pay dividends. Could they change? Acquisition costs for the old policy may have been paid, you will incur You re older are premiums higher for the proposed new policy? costs for the new one. How long will you have to pay premiums on the new policy? What surrender charges do the policies have? On the old policy? What expense and sales charges will you pay on the new policy? Does the new policy provide more insurance coverage? Insurability If you are keeping the old policy as well as the new policy If your health has changed since you bought your old policy, How are premiums for both policies being paid? the new one could cost you more, or you could be turned down. How will the premiums on your existing policy beaffected? You may need a medical exam for a new policy. Will a loan be deducted from death benefits? Claims on most new policies for up to the first two years can be denied based on inaccurate statements. What values from the old policy are being used to pay premiums? Suicide limitations may begin anew on the new coverage. If you are surrendering an annuity or interest sensitive life product Other issues to consider for all transactions Will you pay surrender charges on your old annuity contract? What are the tax consequences of buying the new policy? What are the interest rate guarantees for the new annuity contract? Is this a tax-free exchange? (See your tax advisor)

Have you compared the contract charges or other policy expenses? Is there a benefit from favorable grandfathered treatment of the old policy under the federal tax code? Will the existing insurer be willing to modify the old policy? How does the quality and financial stability of the new company compare with your existing company? New York Life Insurance Company 51 Madison Avenue New York, NY 10010 New York Life Insurance and Annuity Corporation (A Delaware Corporation) 51 Madi son Avenue New York, NY 10010 NYLIFE Insurance Company of Arizona (a subsidiary of New York Life) 4343 North S cottsdale Rd., Suite 220, Scottsdale, AZ 85251 (not licensed in every state) 22190.100 0111:120111014957 ----------------------- Page 3-----------------------

IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR ANNUI TIES This document must be signed by the Applicant and the Producer, and a copy left with the Applicant. You are contemplating the purchase of a life insurance policy or annuity contrac t. In some cases the purchase may involve discontinuing or changing an existing policy or annuity contract. If so, a replacement is occurring. Fina nced purchases are also considered replacements. A replacement occurs when a new policy or annuity contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing policy or annuity contract, or an existing policy or annuity con tract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase. A financed purchase occurs when the purchase of a new life insurance policy invo lves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing policy, to pay all or part of any premium or payment due on the new policy. A financed purchase is a replacement. You should carefully consider whether a replacement is in your best interest. Yo u will pay acquisition costs and there may be surrender costs deducted from your policy or annuity contract. You may be able to make changes to your ex isting policy or annuity contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy and may reduce the amount paid upon the death of the insured. We want you to understand the effects of replacement before you make your purcha se decision and ask that you answer the following questions and consider the questions on the reverse side of this form. 1. ? Do you own any existing life insurance policies or annuity contracts? (If Ye

s , complete questions 2, 3 and 4 below. yes If No , do not answer questions 2, 3 and 4.)

no

? 2. Are you considering discontinuing making premium payments, surrendering, fo rfeiting, assigning to the insurer, yes no or otherwise terminating your existing policy or annuity contract? ? 3. Are you considering using funds from your existing policies or annuity cont racts to pay premiums due on the new yes no policy or annuity contract? ? 4. Is the life insurance policy or annuity contract for which you are applying , to be the result of a 1035 exchange? yes no If you answered Yes to questions 2, 3, or 4, list each existing policy or annuity contract you are contemplating replacing. Also identify for each policy whether it will be replaced, used as a source of financing or replac ed in conjunction with a 1035 exchange. (If additional space is required, complete another form.) United Annuity United Ann Name of Insurance Company ______________________________________________ Policy or Annuity Contract #_____________ ? Marion L Wilmington III Replaced 1035 Exchange Name of Insured or Annuitant _____________________________________________ Financed United Annuity UA12345 Name of Insurance Company ______________________________________________ Policy or Annuity Contract #_____________ ? Marione L Wilmington III Replaced 1035 Exchange Name of Insured or Annuitant _____________________________________________ Financed United Annuity UA12345 Name of Insurance Company ______________________________________________ Policy or Annuity Contract #_____________ ? Eileen L Wilmington III Replaced 1035 Exchange Name of Insured or Annuitant _____________________________________________ Financed United Annuity UA12345 Name of Insurance Company ______________________________________________ Policy or Annuity Contract #_____________

? Lilian L Wilmington III Replaced 1035 Exchange Name of Insured or Annuitant _____________________________________________ Financed Make sure you know the facts. Contact your existing company or its producer for information about the old policy or annuity contract. At your request, the existing insurer must send you an in-force illustration, polic y summary or available disclosure documents. Ask for and retain all sales material used by the producer in the sales presentation. Be sur e that you are making an informed decision. The existing policy(ies) or annuity contract(s) is/are being considered for repl acement because ____________________________________ Better company rating _______________________________________________________________________________ _______________________________ _______________________________________________________________________________ _______________________________ _______________________________________________________________________________ _______________________________ I do not want this notice read aloud to me. (Applicant must initial only if they do not want the notice read aloud.) I certify that the responses herein are, to the best of my knowledge, accurat e: Applicant s Signature Applicant s Name (Printed) S Massachusetts t c a Matthew X X v / / e p F d D F I Producer Acknowledgement: By reason of this transaction, is replacement involv ed? yes no H a C t Producer s Signature e e E Producer s Name (Printed) r R Date e m A Sowmya i O Date

e e X / 22190.100 0111:120111014957 ----------------------- Page 4----------------------/ X WILLIAM CUSTOMER COPY E MAHONEY

IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR A NNUITIES Important considerations if you are contemplating replacing your existing policy or annuity contract A replacement may not be in your best interest, or your decision could be a goo d one. You should make a careful comparison of the costs and benefits of your existing policy or annuity contract and the proposed policy or annuity contract. One way to do this is to ask the company or producer that sold you your existing policy or annuity contract to provide you with information co ncerning your existing policy or annuity contract. This may include an illustration of how your existing policy or annuity contra ct is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to com pare policies or annuity contracts. You should discuss the following with your producer to determine whether replacement or financing your purchase makes sense: Premiums Policy Values Are they affordable? New policies usually take longer to build cash values and to pay dividends. Could they change? Acquisition costs for the old policy may have been paid, you will incur You re older are premiums higher for the proposed new policy? costs for the new one. How long will you have to pay premiums on the new policy? What surrender charges do the policies have? On the old policy? What expense and sales charges will you pay on the new policy? Does the new policy provide more insurance coverage? Insurability If you are keeping the old policy as well as the new policy If your health has changed since you bought your old policy, How are premiums for both policies being paid?

the new one could cost you more, or you could be turned down. How will the premiums on your existing policy beaffected? You may need a medical exam for a new policy. Will a loan be deducted from death benefits? Claims on most new policies for up to the first two years can be denied based on inaccurate statements. What values from the old policy are being used to pay premiums? Suicide limitations may begin anew on the new coverage. If you are surrendering an annuity or interest sensitive life product Other issues to consider for all transactions Will you pay surrender charges on your old annuity contract? What are the tax consequences of buying the new policy? What are the interest rate guarantees for the new annuity contract? Is this a tax-free exchange? (See your tax advisor) Have you compared the contract charges or other policy expenses? Is there a benefit from favorable grandfathered treatment of the old policy under the federal tax code? Will the existing insurer be willing to modify the old policy? How does the quality and financial stability of the new company compare with your existing company? New York Life Insurance Company 51 Madison Avenue New York, NY 10010 New York Life Insurance and Annuity Corporation (A Delaware Corporation) 51 Madi son Avenue New York, NY 10010 NYLIFE Insurance Company of Arizona (a subsidiary of New York Life) 4343 North S cottsdale Rd., Suite 220, Scottsdale, AZ 85251 (not licensed in every state) 22190.100 COPY CUSTOMER 0111:120111014957