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New York Life Insurance Company New York Life Insurance and Annuity Corporation (A Delaware Corporation) 51 Madison Avenue, New York, New York 10010 NYLIFE Insurance Company of Arizona (Not licensed in every state) 4343 North Scottsdale Road, Suite 220, Scottsdale, AZ 85251



Assignments of policies issued by the Company or Corporation must be made in duplicate. We will retain one copy and the other will be returned.

Executor or Administrator When an executor or administrator executes an assignment it should be accompanied by an official certificate certifying that such executor or administrator is still acting in such capacity.

Corporations An assignment by a Corporation must be signed by two Corporate Officers on behalf of the Corporation; one such officer may be either the Treasurer or Secretary of the Corporation.

Beneficiaries If the policy is issued prior to the "944" series as introduced by the Company on June 13, 1944, the beneficiary, if any, should agree to the assignment if of legal age. If the beneficiary on such a policy is a minor, the beneficiary's legally appointed guardian, as court authorized, should agree to the assignment on behalf of such minor. A certificate showing the qualification of such guardian and a certified copy of the court order authorizing the guardian to make the assignment should accompany this form.

In Exchange for Value Received, ________________________________________________, being of legal age, hereby

Name of Assignor

assigns to ________________________________________________________________________________________

Name of Assignee


Address of Assignee

as collateral security, Policy No. _______________________ issued by New York Life Insurance Company ("Company") or New York Life Insurance and Annuity Corporation ("Corporation") or NYLIFE Insurance Company of Arizona ("Company") on the life of:

_____________________________________________________________________________________ (the Insured).

This assignment is subject to the terms and conditions of the policy, and to any debt owed to the Company or Corporation against the policy. If the policy is eligible for dividends, the Assignor reserves the right to withdraw any dividends now credited or which may be credited in the future to the policy. If any default in payment of the debt secured by this assignment occurs, the Assignee, its Successors or Assigns may exercise the right, when available to the policyowner under the terms of the policy, to: (a) establish a loan, (b) secure payment of its cash surrender value or (c) have it endorsed for its reduced paid-up insurance. If the policy becomes a claim by reason of death or otherwise, upon receipt of a written statement indicating the outstanding amount of the Assignor's indebtedness, the Company or Corporation is authorized to pay the Assignee the amount needed to satisfy the Assignor's debt. The balance, if any, will be paid to the Policyowner or Beneficiary as applicable. Any Disability Benefits provided under the policy are not assigned.

The Assignor hereby authorizes the Company or Corporation to recognize the Assignee's claims to rights under this assignment without investigating the reason for any action taken by the Assignee, or the validity or the amount of the default in payment of the debt secured by this assignment, or the giving of any notice to the Assignor, or the application to be made by the Assignee of any amounts to be paid to the Assignee. The Assignor also authorizes the Company or Corporation to provide information regarding policy status to the Assignee. The Company's or Corporation's payment to the Assignee in accordance with this assignment fully releases the Company or Corporation from any further obligation. The Assignor hereby acknowledges that the Assignee's claim is superior to that of any Beneficiary.

______________ Date

X ______________________________________________________ (____)____________

Policyowner's Signature (if Corporate Officer, include title)

Phone Number

______________ Date

X ______________________________________________________ (____)____________

Additional Signature, if required (if Corporate Officer, include title)

Phone Number

NEW YORK LIFE INSURANCE COMPANY or NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION or NYLIFE INSURANCE COMPANY OF ARIZONA has retained the duplicate copy of this assignment. The Company or Corporation assumes no responsibility for the validity of the assignment.

______________ Date

________________________________________________________ Signature for the Company or Corporation

FOR OFFICE USE ONLY Date Premiums Paid To _________________________ Returned To ___________________________________ By _____________________ Date _________________

Date Received Stamp Here

6451 (12/04)

[Agent return form to Service Center]


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