SEC Info - Jnlny Separate Account I, et al. - ‘485BPOS’ on 4/29/04

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Jnlny Separate Account I, et al. – ‘485BPOS’ on 4/29/04 – EX-99

On: Thursday, 4/29/04, at 5:57pm ET · As of: 4/30/04 · Effective: 5/1/04 · Accession #: 927730-4-156 · File #s: 333-70384, 811-08401

  As Of                Filer                Filing    For·On·As Docs:Size              Issuer               Agent

 4/30/04  Jnlny Separate Account I          485BPOS     5/01/04    5:1.1M                                   Jackson Nat’l Sep A… - I
          Jnlny Separate Account I

Post-Effective Amendment
Filing Table of Contents

Document/Exhibit                   Description                      Pages   Size 

 1: 485BPOS     Post-Effective Amendment                             599±  3.12M 
 2: EX-99       Miscellaneous Exhibit                                  5     23K 
 3: EX-99       Miscellaneous Exhibit                                  9±    38K 
 4: EX-99       Miscellaneous Exhibit                                  1      8K 
 5: EX-99       Miscellaneous Exhibit                                  1      6K

EX-99 — Miscellaneous Exhibit

EX-99 1st “Page” of 4 TOC ↑Top Previous Next ↓Bottom Just 1st
 
                                                                      EX-99.5.d.

                                                        [Enlarge/Download Table]

                                                                                          

perspective II(SM) (05/04)                         JACKSON NATIONAL LIFE [GRAPHIC OMITTED]
FIXED AND VARIABLE ANNUITY APPLICATION     INSURANCE COMPANY OF NEW YORK                  
                                        Home Office - 2900 Westchester Ave., Ste. 305     
See back page for mailing address.                                 Purchase, NY 10577     
USE DARK INK, ONLY                                                      WWW.JNLNY.COM     

--------------------------------------------------------------------------------
REGISTRATION INFORMATION                                                        
--------------------------------------------------------------------------------
OWNER'S NAME                                                                    
--------------------------------------------------------------------------------
SSN/TIN (include dashes)                                                        
--------------------------------------------------------------------------------
Home Address (number and street)                                                
--------------------------------------------------------------------------------
CITY, STATE, ZIP                                                                
--------------------------------------------------------------------------------
Broker/Dealer Acct. Number                                                      
--------------------------------------------------------------------------------
Date of Birth (mm/dd/yyyy)                                                      
--------------------------------------------------------------------------------
Age                                                                             
--------------------------------------------------------------------------------
Sex           M ___  F ___                                                      
--------------------------------------------------------------------------------
U.S. Citizen    Yes ___  No ___                                                 
--------------------------------------------------------------------------------
Phone No. (include area code)                                                   
--------------------------------------------------------------------------------
E-Mail Address                                                                  
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JOINT OWNER'S NAME (Proceeds will be distributed in accordance with the Contract
on the first death of either Owner. Spousal Joint Owner may continue the        
contract.)                                                                      
--------------------------------------------------------------------------------
SSN/TIN (include dashes)                                                        
--------------------------------------------------------------------------------
Home Address (number and street)                                                
--------------------------------------------------------------------------------
CITY, STATE, ZIP                                                                
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Relationship to Owner                                                           
--------------------------------------------------------------------------------
Date of Birth (mm/dd/yyyy)                                                      
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Age                                                                             
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Sex           M ___  F ___                                                      
--------------------------------------------------------------------------------
U.S. Citizen    Yes ___  No ___                                                 
--------------------------------------------------------------------------------
Phone No. (include area code)                                                   
--------------------------------------------------------------------------------
E-Mail Address                                                                  
--------------------------------------------------------------------------------
ANNUITANT'S NAME (if other than Owner)                                          
--------------------------------------------------------------------------------
SSN/TIN (include dashes)                                                        
--------------------------------------------------------------------------------
Home Address (number and street)                                                
--------------------------------------------------------------------------------
CITY, STATE, ZIP                                                                
--------------------------------------------------------------------------------
Date of Birth (mm/dd/yyyy)                                                      
--------------------------------------------------------------------------------
Age                                                                             
--------------------------------------------------------------------------------
Sex           M ___  F ___                                                      
--------------------------------------------------------------------------------
U.S. Citizen    Yes ___  No ___                                                 
--------------------------------------------------------------------------------
Phone No. (include area code)                                                   
--------------------------------------------------------------------------------
E-Mail Address                                                                  
--------------------------------------------------------------------------------
JOINT ANNUITANT'S NAME                                                          
--------------------------------------------------------------------------------
SSN/TIN (include dashes)                                                        
--------------------------------------------------------------------------------
Date of Birth (mm/dd/yyyy)                                                      
--------------------------------------------------------------------------------
Age                                                                             
--------------------------------------------------------------------------------
Sex           M ___  F ___                                                      
--------------------------------------------------------------------------------
U.S. Citizen    Yes ___  No ___                                                 
--------------------------------------------------------------------------------
Phone No. (include area code)                                                   
--------------------------------------------------------------------------------
BENEFICIARY DESIGNATION                                                         
--------------------------------------------------------------------------------
Percentages  must  equal  100%  for  each   beneficiary   type.  For  additional
beneficiaries,  please attach a separate  sheet,  signed and dated by the Owner,
which includes names, percentages, and other required information.              
--------------------------------------------------------------------------------
Primary                                                                         
--------------------------------------------------------------------------------
Name                                                                            
--------------------------------------------------------------------------------
SSN/TIN (include dashes)                                                        
--------------------------------------------------------------------------------
Percentage (%)                                                                  
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Relationship to Owner                                                           
--------------------------------------------------------------------------------
Address (number and street)                                                     
--------------------------------------------------------------------------------
City, State, ZIP                                                                
--------------------------------------------------------------------------------
___ Primary                                                                     
___ Contingent Name                                                             
--------------------------------------------------------------------------------
SSN/TIN (include dashes)                                                        
--------------------------------------------------------------------------------
Percentage (%)                                                                  
--------------------------------------------------------------------------------
Relationship to Owner                                                           
--------------------------------------------------------------------------------
Address (number and street)                                                     
--------------------------------------------------------------------------------
City, State, ZIP                                                                
--------------------------------------------------------------------------------
Name                                                                            
--------------------------------------------------------------------------------
___ Primary                                                                     
___ Contingent Name                                                             
--------------------------------------------------------------------------------
SSN/TIN (include dashes)                                                        
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Percentage (%)                                                                  
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Relationship to Owner                                                           
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Address (number and street)                                                     
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City, State, ZIP                                                                
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___ Primary                                                                     
___ Contingent Name                                                             
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SSN/TIN (include dashes)                                                        
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Percentage (%)                                                                  
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Relationship to Owner                                                           
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Address (number and street)                                                     
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City, State, ZIP                                                                
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ANNUITY TYPE                                                                    
--------------------------------------------------------------------------------
___  Non-Tax Qualified                                                          
___  401(k) Qualified Savings Plan                                              
___  HR-10 (Keogh) Plan                                                         
___  403(b) TSA (Direct Transfer Only)                                          
___  IRA - SEP                                                                  
___  Other __________________________________                                   

___  IRA - Individual*                                                          
___  IRA - Custodial*                                                           
___  IRA - Roth*                                                                
*Tax Contribution Years and Amounts:                                            
Year: ________  $__________                                                     
Year: ________  $__________                                                     

--------------------------------------------------------------------------------
TRANSFER INFORMATION                                                            
--------------------------------------------------------------------------------
___  IRC 1035 Exchange                                                          
___  Direct Transfer                                                            
___  Direct Rollover                                                            
___  Non-Direct Rollover                                                        
___  Roth Conversion                                                            

NVDA 105 05/04                                                 NV4373 Rev. 05/04

EX-99 2nd “Page” of 4 TOC 1st Previous Next ↓Bottom Just 2nd
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REPLACEMENT                                                                     
* Must be completed for "Good-Order"                                            
--------------------------------------------------------------------------------
Are you replacing an existing life insurance policy or annuity contract?*       
____   Yes   ____  No     If "Yes", please complete this section.               
--------------------------------------------------------------------------------
Company Name                                                                    
--------------------------------------------------------------------------------
Contract No.                                                                    
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Anticipated Transfer Amount                                                     
$                                                                               
--------------------------------------------------------------------------------
Company Name                                                                    
--------------------------------------------------------------------------------
Contract No.                                                                    
Anticipated Transfer Amount                                                     
$                                                                               
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INITIAL PREMIUM                                                                 
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Amount of premium with application: $                                           
MAKE ALL CHECKS PAYABLE TO JACKSON NATIONAL LIFE INSURANCE COMPANY OF NEW       
YORK[SM]                                                                        
--------------------------------------------------------------------------------
INCOME DATE                                                                     
--------------------------------------------------------------------------------
Please specify date (mm/dd/yyyy): _________________                             
If an Income Date is not specified, age 90 (age 70 1/2 for Qualified Plans) of  
the Owner will be used.                                                         
--------------------------------------------------------------------------------
CAPITAL PROTECTION PROGRAM                                                      
--------------------------------------------------------------------------------
___  Yes  PLEASE COMPLETE SUPPLEMENTAL APPLICATION N3144.                       
___  No  PLEASE PROCEED TO THE PREMIUM ALLOCATION SECTION.                      
--------------------------------------------------------------------------------
PREMIUM ALLOCATION    WHOLE PERCENTAGES ONLY    TOTAL ALLOCATION MUST EQUAL 100%
--------------------------------------------------------------------------------
PORTFOLIOS (%)                                                                  

___ JNL[R]/AIM Large Cap Growth                                                 
___ JNL/AIM Small Cap Growth                                                    
___ JNL/Alger Growth                                                            
___ JNL/Alliance Capital Growth                                                 
___ JNL/Eagle Core Equity                                                       
___ JNL/Eagle SmallCap Equity                                                   
___ JNL/FMR Balanced JNL/FMR Capital Growth                                     
___ JNL/JPMorgan International Value                                            
___ JNL/Lazard Mid Cap Value                                                    
___ JNL/Lazard Small Cap Value                                                  
___ JNL/Mellon Capital Management S&P[R] 500 Index                              
___ JNL/Mellon Capital Management S&P 400 MidCap Index                          
___ JNL/Mellon Capital Management Small Cap Index                               
___ JNL/Mellon Capital Management International Index                           
___ JNL/Mellon Capital Management Bond Index                                    
___ JNL/Mellon Capital Management The Dow[SM] 10                                
___ JNL/Mellon Capital Management The S&P[R] 10                                 
___ JNL/Mellon Capital Management Global 15                                     
___ JNL/Mellon Capital Management 25                                            
___ JNL/Mellon Capital Management Select Small-Cap                              
___ JNL/Mellon Capital Management Communications Sector                         
___ JNL/Mellon Capital Management Consumer Brands Sector                        
___ JNL/Mellon Capital Management Energy Sector                                 
___ JNL/Mellon Capital Management Financial Sector                              
___ JNL/Mellon Capital Management Pharmaceutical/ Healthcare Sector             
___ JNL/Mellon Capital Management Technology Sector                             
___ JNL/Mellon Capital Management Enhanced S&P 500 Stock Index                  
___ JNL/Oppenheimer Global Growth                                               
___ JNL/Oppenheimer Growth                                                      

PORTFOLIOS (%)                                                                  

___ JNL/PIMCO Total Return Bond                                                 
___ JNL/PPM America Balanced                                                    
___ JNL/PPM America High Yield Bond                                             
___ JNL/PPM America Money Market                                                
___ JNL/PPM America Value                                                       
___ JNL/Putnam Equity                                                           
___ JNL/Putnam International Equity                                             
___ JNL/Putnam Midcap Growth                                                    
___ JNL/Putnam Value Equity                                                     
___ JNL/Salomon Brothers Strategic Bond                                         
___ JNL/Salomon Brothers U.S. Government & Quality Bond                         
___ JNL/Select Large Cap Growth                                                 
___ JNL/Select Global Growth                                                    
___ JNL/T. Rowe Price Established Growth                                        
___ JNL/T. Rowe Price Mid-Cap Growth                                            
___ JNL/T. Rowe Price Value                                                     
___ JNL/S&P Aggressive Growth I                                                 
___ JNL/S&P Conservative Growth I                                               
___ JNL/S&P Equity Aggressive Growth I                                          
___ JNL/S&P Equity Growth I                                                     
___ JNL/S&P Moderate Growth I                                                   
___ JNL/S&P Very Aggressive Growth I                                            
___ JNL/S&P Core Index 50                                                       
___ JNL/S&P Core Index 75                                                       
___ JNL/S&P Core Index 100                                                      

FIXED ACCOUNT OPTIONS                                                           
___ 1-year                                                                      
___ 3-year                                                                      
___ 5-year                                                                      
___ 7-year                                                                      

NVDA 105 05/04                                                 NV4373 Rev. 05/04

EX-99 3rd “Page” of 4 TOC 1st Previous Next ↓Bottom Just 3rd
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OPTIONAL BENEFITS - ONCE SELECTED, OPTIONAL BENEFITS CANNOT BE CHANGED.         
--------------------------------------------------------------------------------
A. CONTRACT ENHANCEMENT OPTIONS[1] (MAY SELECT ONLY ONE)                        
____  2% of first-year premium [2]                                        
____  3% of first-year premium [2]                                        
____  4% of first-year premium [2]                                        
B. WITHDRAWAL OPTIONS                                                           
____  20% Additional Withdrawal Benefit [3] [4]                         
____  3-Year Withdrawal Charge Schedule                                 
____  5-Year Withdrawal Charge Schedule [4]                             
C.  GUARANTEED LIVING BENEFIT OPTIONS (MAY SELECT ONLY ONE)                     
____  FutureGuard[SM] (see NOTE below) (Guaranteed Minimum              
Income Benefit)                                             
____  SafeGuard[SM] - 7% (see NOTE below)                               
(Guaranteed Minimum Withdrawal Benefit)                     

[1] Please complete the Important Disclosure Regarding the                      
Contract Enhancement.                                                   
[2] Selection of the 2%, 3%, or 4% Contract Enhancement option will prohibit    
  allocation or transfer of any premium to the 3, 5, or 7-Year Fixed Account
Options during the Recapture period of that selected option.            
[3] May not be selected in combination with the 3% or 4% Contract Enhancement.  
[4] May not be selected in combination with the 3-Year Withdrawal Charge        
Schedule.                                                               

NOTE: The GMIB and GMWB may not be appropriate for Owners who will be subject to
any minimum distribution requirements under an IRA or other qualified plan prior
to the expiration of 10 contract years.                                         

Exercise of the GMWB benefit after the required minimum  distribution  beginning
date under an IRA or other qualified plan may not be appropriate.               

Please consult a tax advisor on this and other matters of selecting income      
options.                                                                        

ADDITIONAL CHARGES WILL APPLY. PLEASE SEE THE PROSPECTUS FOR DETAILS. 
--------------------------------------------------------------------------------
OPTIONAL DEATH BENEFIT - ONCE SELECTED, OPTIONAL BENEFITS CANNOT BE CHANGED.    
--------------------------------------------------------------------------------
If the Optional Death Benefit is not selected, your beneficiary(ies) will       
receive the standard death benefit. Please see the prospectus for details.      

____ Highest Anniversary Value Death Benefit.                                   

 ADDITIONAL CHARGES WILL APPLY. PLEASE SEE THE PROSPECTUS FOR DETAILS.
--------------------------------------------------------------------------------
IMPORTANT - PLEASE READ CAREFULLY.                                              
--------------------------------------------------------------------------------
1. I (We) hereby represent to the best of my (our) knowledge and belief that    
each of the statements and answers contained above are true, complete and 
correctly recorded.                                                       
2. I (We) certify that the Social Security or Taxpayer Identification number(s) 
shown above is (are) correct.                                             
3. I (WE) UNDERSTAND THAT ANNUITY BENEFITS AND WITHDRAWAL VALUES, IF ANY, WHEN  
  BASED ON THE INVESTMENT EXPERIENCE OF A PORTFOLIO IN THE SEPARATE ACCOUNT OF
JNL[R]/NY ARE VARIABLE AND MAY BE INCREASED OR DECREASED, AND THE DOLLAR  
AMOUNTS ARE NOT GUARANTEED.                                               
4. I (We) have been given a current prospectus for this variable annuity for    
each available Portfolio listed above.                                    
5. The contract I (we) have applied for is suitable for my (our) insurance      
objective, financial situation and needs.                                 
6. I understand the restrictions imposed by 403(b)(11) of the Internal Revenue  
  Code. I understand the investment alternatives available under my employer's
403(b) plan, to which I may elect to transfer my contract value.          
7. I (WE) UNDERSTAND THAT ALLOCATIONS TO THE FIXED ACCOUNT OPTION(S) ARE SUBJECT
TO AN ADJUSTMENT IF WITHDRAWN OR TRANSFERRED PRIOR TO THE END OF THE      
APPLICABLE PERIOD, WHICH MAY REDUCE AMOUNTS WITHDRAWN OR TRANSFERRED.     
8. If I (we) have elected the Capital Protection Program, I (we) hereby         
acknowledge receipt of the "CAPITAL PROTECTION PROGRAM SUPPLEMENTAL       
APPLICATION."                                                             
--------------------------------------------------------------------------------
STATEMENTS/CORRESPONDENCE                                                       
--------------------------------------------------------------------------------
I ___ ELECT ___ ELECT NOT to receive correspondence, including but not limited  
to annual and semi-annual reports, quarterly and immediate confirms and         
prospectuses (except ______________________________________) electronically from
Jackson National Life of New York, when available.                              

If you elect to receive any or all of such documents electronically and         
subsequently (or later) wish to discontinue electronic delivery of any or all of
these types of documents, contact us at our Service Center.                     

NVDA 105 05/04                                                 NV4373 Rev. 05/04

EX-99 Last “Page” of 4 TOC 1st Previous Next ↓Bottom Just 4th
SIGNATURES* Must be completed for "Good-Order"                                  
--------------------------------------------------------------------------------
SIGNED AT (city, state)                                                         
--------------------------------------------------------------------------------
DATE SIGNED (mm/dd/yyyy)                                                        
--------------------------------------------------------------------------------
Owner's Signature                                                               
--------------------------------------------------------------------------------
Annuitant's Signature (if other than Owner)                                     
--------------------------------------------------------------------------------
Joint Owner's Signature                                                         
--------------------------------------------------------------------------------
Joint Annuitant's Signature (if other than Joint Owner)                         
--------------------------------------------------------------------------------
PRODUCER/FINANCIAL REPRESENTATIVE'S STATEMENT                                   
--------------------------------------------------------------------------------
I certify that: I am authorized and qualified to discuss the Contract herein    
applied for; I have fully explained the Contract to the client, including       
contract restrictions and charges; I believe this transaction is suitable given 
the client's financial situation and needs; I have complied with requirements   
for disclosures and/or replacements as necessary; and to the best of my         
knowledge and belief the applicant's statement as to whether or not an existing 
life insurance policy or annuity contract is being replaced is true and         
accurate. (If a replacement, please provide a replacement form or other special 
forms where required by state law.)                                             
--------------------------------------------------------------------------------
Producer/Financial Representative's Full Name (please print)                    
--------------------------------------------------------------------------------
Phone No. (include area code)                                                   
--------------------------------------------------------------------------------
Producer/Financial Representative's Signature                                   
--------------------------------------------------------------------------------
Date Signed (mm/dd/yyyy)                                                        
--------------------------------------------------------------------------------
Address (number and street)                                                     
--------------------------------------------------------------------------------
City, State, ZIP                                                                
--------------------------------------------------------------------------------
E-Mail Address                                                                  
--------------------------------------------------------------------------------
Contact your home office for program information.                               
___ Option A      ___ Option B      ___ Option C      ___ Option D  
--------------------------------------------------------------------------------
Broker/Dealer Name                                                              
--------------------------------------------------------------------------------
Broker/Dealer Representative No.                                                
--------------------------------------------------------------------------------
JNL/NY Producer/Representative No.                                              
--------------------------------------------------------------------------------
 MAILING ADDRESS AND CONTACT INFORMATION

FOR CONTRACTS PURCHASED THROUGH A NON-BANK BROKER/DEALER, SEND TO:              

REGULAR MAIL
 JNL/NY Service Center
 P.O. Box 378004
 Denver, CO 80237-8004

OVERNIGHT MAIL
 JNL/NY Service Center
 8055 E. Tufts Ave., 2nd floor
Denver, CO 80237

 CUSTOMER CARE: 800/599-5651 (9:00 a.m. to 8:00 p.m. ET)
 FAX: 800/701-0125
 E-MAIL: contactus@jnlny.com

--------------------------------------------------------------------------------
FOR CONTRACTS PURCHASED THROUGH A BANK OR FINANCIAL INSTITUTION, SEND TO:       

REGULAR MAIL
 JNL/NY IMG Service Center
P.O. Box 33178
Detroit, MI 48232-5178

OVERNIGHT MAIL
 JNL/NY IMG Service Center
 c/o Drawer 5178
 12425 Merriman Road
Livonia, MI 48151-0688

 CUSTOMER CARE: 888/464-7779 (8:00 a.m. to 8:00 p.m. ET)
 FAX: 517/367-4669
 E-MAIL: contactus@jnlny.com

 Not FDIC/NCUA insured * Not Bank/CU guaranteed * May lose value * Not a deposit
 * Not insured by any federal agency

NVDA 105 05/04                                                 NV4373 Rev. 05/04

EX-99	1st “Page” of 4	TOC	↑Top	Previous	Next	↓Bottom	Just 1st

EX-99	2nd “Page” of 4	TOC	1st	Previous	Next	↓Bottom	Just 2nd

EX-99	3rd “Page” of 4	TOC	1st	Previous	Next	↓Bottom	Just 3rd

EX-99	Last “Page” of 4	TOC	1st	Previous	Next	↓Bottom	Just 4th

4 Subsequent Filings that Reference this Filing

  As Of               Filer                 Filing    For·On·As Docs:Size             Issuer                      Filing Agent

 4/25/24  Jnlny Separate Account I          485BPOS     4/29/24    3:6.1M
 4/27/23  Jnlny Separate Account I          485BPOS     5/01/23    3:5.9M
 4/21/22  Jnlny Separate Account I          485BPOS     4/25/22    3:6M
 4/22/21  Jnlny Separate Account I          485BPOS     4/26/21    3:27M

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Filing Submission 0000927730-04-000156 – Alternative Formats (Word / Rich Text, HTML, Plain Text, et al.)

Jnlny Separate Account I, et al. – ‘485BPOS’ on 4/29/04 – EX-99

On: Thursday, 4/29/04, at 5:57pm ET · As of: 4/30/04 · Effective: 5/1/04 · Accession #: 927730-4-156 · File #s: 333-70384, 811-08401

Post-Effective AmendmentFiling Table of Contents

EX-99 — Miscellaneous Exhibit

4 Subsequent Filings that Reference this Filing

Post-Effective Amendment
Filing Table of Contents