ELITE ACCESS ADVISORY II (04/20) INDIVIDUAL VARIABLE ANNUITY APPLICATION (VA785NY) Home Office: Purchase, NY 10577 Jackson National Life Insurance Company www.jackson.com of New York First Class Mail: P.O. Box 30314 Lansing, MI 48909-7814 Customer Care: 800-599-5651 Fax:
888-576-8383 Overnight Mail: 1 Corporate Way Email: customercare@jackson.com Lansing, MI 48951 Linking/BIN/Brokerage Acct. Number (if applicable) Jackson of NY pre-assigned Contract Number (if applicable) Primary Owner PLEASE PRINT Type of Ownership: CLEARLY Individual/Joint Custodian Trust Corporation/Pension Plan Government Entity Please see the Good Order Checklist for Social Security Number or Tax ID Number Phone Number (include area code) additional requirements. Country of Residence If
U.S. U.S. Citizen Yes No Sex Male Female citizenship is not selected, Date of Birth (mm/dd/yyyy) Email Address (print clearly) and a Social Security Number with a U.S. address is First Name Middle Name Last Name listed, along with the absence of any other foreign Non-Natural Owner/Entity Name (if applicable) indicator, Jackson National Life Physical Address Line 1 (No P.O. Boxes) Physical Address Line 2 Insurance Company of New York (Jackson of NY) Physical Address City State ZIP will assume an active U.S. citizenship status. Mailing Address Line 1 Mailing Address Line 2 Mailing Address City State ZIP NVDA 785 04/19 Page 1 of 11 NV785 04/20
Joint Owner Social Security Number Date of Birth (mm/dd/yyyy) Email Address (print clearly) Country of Residence U.S. Citizen Yes No Sex Male Female In the case of First Name Middle Name Last Name Joint Owners, all correspondence Relationship to Owner Phone Number (include area code) and required documentation will be sent to the address of Physical Address Line 1 (No P.O. Boxes) Physical Address Line 2 the Primary Owner. Physical Address City State ZIP Primary Annuitant Complete this Social Security Number Date of Birth (mm/dd/yyyy) Phone Number (include area code) section if different than Primary Owner. If Primary Country of Residence Annuitant section is left U.S. Citizen Yes No Sex Male Female blank, the Annuitant will First Name Middle Name Last Name default to the Primary Owner. Physical Address Line 1 (No P.O. Boxes) Physical Address Line 2 Physical Address City State ZIP Joint
Annuitant Complete this Social Security Number Date of Birth (mm/dd/yyyy) section if different than Joint Annuitant Not Applicable Joint Owner. If Joint Annuitant Country of Residence section is left U.S. Citizen Yes No Sex Male Female blank, the Joint Annuitant will First Name Middle Name Last Name default to the Joint Owner. Relationship to Primary Annuitant Phone Number (include area code) Physical Address Line 1 (No P.O. Boxes) Physical Address Line 2 Physical Address City State ZIP NVDA 785 04/19 Page 2 of 11 NV785 04/20
Beneficiary(ies) Percentage of Primary Sex Male Female % It is required for Death Benefit Good Order that the Social Security/Tax ID Number Date of Birth (mm/dd/yyyy) Relationship to Owner Percentage of Death Benefit be whole First Name Middle Name Last Name numbers and must total 100% for each beneficiary Non-Natural Owner/Entity Name (if applicable) Phone Number (include area code) type. If Percentage of Death Benefit is Physical Address Line 1 (No P.O. Boxes) Physical Address Line 2 left blank, all beneficiaries will receive equal shares. Physical Address City State ZIP Please use form Percentage of N3041 for Primary Contingent Sex Male Female % additional Death Benefit beneficiaries. Social Security/Tax ID Number Date of Birth (mm/dd/yyyy) Relationship to Owner First Name Middle Name Last Name Non-Natural Owner/Entity Name (if applicable) Phone Number (include area code) Physical Address
Line 1 (No P.O. Boxes) Physical Address Line 2 Physical Address City State ZIP Percentage of Primary Contingent Sex Male Female % Death Benefit Social Security/Tax ID Number Date of Birth (mm/dd/yyyy) Relationship to Owner First Name Middle Name Last Name Non-Natural Owner/Entity Name (if applicable) Phone Number (include area code) Physical Address Line 1 (No P.O. Boxes) Physical Address Line 2 Physical Address City State ZIP NVDA 785 04/19 Page 3 of 11 NV785 04/20
Annuity Type The Variable Annuity Non-Tax Qualified IRA - Traditional* Roth IRA* SEP 403(b) TSA Automatic Withdrawal Stretch IRA Non-Qualified Stretch Roth Conversion Other: Request form (NV4370) will *Tax Contribution Year(s) and Amounts: be required if a Stretch Annuity Year: $ Year: $ Type is elected. Premium Payment External Select method of payment and note approximate amount: Transfers: The Request for Check Attached $ Check In Transit $ Wire $ Transfer or Exchange of Assets form (N3783) must Anticipated total amount from internal transfer(s) $ be submitted if Jackson of NY is to request the Anticipated total amount from external transfer(s) to be requested by Jackson of NY $ release of funds. Anticipated total amount from external transfer(s) to be requested by Financial Professional or Owner (Jackson of NY will NOT request funds) $ For more than two account transfers, If Jackson of NY is NOT
requesting funds, please provide the following information: please provide Transfer Anticipated account Company releasing funds Account number Maturity date type transfer amount information on the Letter of Full $ Instruction form Partial (N4250) and submit with application. Full $ Partial Statement Regarding Replacement of Existing Policies or Annuity Contracts It is required for Good Order that this entire section be Do you intend to replace an existing life insurance policy or annuity contract? No Yes completed. If replacing, Jackson of NY pre-assigned Contract number: please provide the Jackson of NY Please complete all necessary forms as required by New York Regulation 60. pre-assigned Contract number. Annuitization/Income Date Specify Income Date (mm/dd/yyyy) If an Annuitization/Income Date is not specified, the Company will default to the Latest Income Date as shown in the Contract. NVDA 785 04/19 Page 4 of 11 NV785 04/20
Premium Allocation Tell us how you JNL Aggressive JNL/American Funds JNL/BlackRock want your Growth Allocation (072) Balanced (150) Advantage annuity International (700) Premiums JNL Conservative JNL/American Funds invested. Whole Allocation (380) Blue Chip Income JNL/BlackRock percentages JNL Growth and Growth (339) Global Allocation (345) only. TOTAL Allocation (071) JNL/American Funds JNL/BlackRock ALLOCATION JNL iShares Capital Income Builder (685) Global Natural MUST EQUAL Tactical Growth (391) JNL/American Funds Resources (066) 100%. JNL iShares Capital World Bond (340) JNL/BlackRock Tactical Moderate (389) JNL/American Funds Large Cap Select Growth (102) JNL iShares Global Growth (638) Total number Tactical Moderate JNL/American Funds JNL/Boston Partners of allocation Growth (390) Global Small Global Long Short selections may Equity (653) not exceed 99. JNL Moderate Capitalization (341) Allocation (381) JNL/American
Funds JNL/Causeway International Value Select (126) JNL Moderate Growth (395) Growth Allocation (070) JNL/American Funds JNL/ClearBridge Large Cap Growth (364) JNL Multi-Manager Growth Allocation (358) Alternative (655) JNL/American Funds JNL/DFA Growth Allocation (664) JNL Multi-Manager Growth-Income (342) Certain Emerging Markets JNL/American Funds JNL/DFA broker-dealers Equity (077) International (343) International may limit the Core Equity (701) Investment JNL Multi-Manager JNL/American Funds International Moderate Growth JNL/DFA Divisions and Moderate Growth Fixed Account Small Cap (686) Allocation (357) Allocation (665) Options JNL Multi-Manager JNL/American Funds available under Mid Cap (663) New World (344) JNL/DFA the Contract. U.S. Core Equity (115) Please see JNL Multi-Manager JNL/AQR Client Small Cap Growth (116) Large Cap Defensive JNL/DFA U.S. Small Cap (612) Acknowledg- JNL Multi-Manager Style (699)
ments on page Small Cap Value (208) JNL/AQR JNL/DoubleLine 10. Large Cap Relaxed Core Fixed Income (127) Constraint Equity (068) JNL/DoubleLine JNL/AQR Emerging Markets Managed Futures Fixed Income (661) Strategy (379) JNL/DoubleLine Shiller Enhanced CAPE (659) JNL/DoubleLine Total Return (636) PREMIUM ALLOCATIONS CONTINUED ON PAGES 6 AND 7. NVDA 785 04/19 Page 5 of 11 NV785 04/20
Premium Allocation (continued from page 5) JNL/Fidelity Institutional JNL/JPMorgan JNL/Mellon Total number Asset Management Global Allocation (644) Healthcare Sector (188) of allocation Total Bond (110) selections may JNL/JPMorgan JNL/Mellon not exceed 99. JNL/First State Growth & Income (064) Index 5 (242) Global Infrastructure (347) JNL/JPMorgan JNL/Mellon JNL/Franklin Templeton Hedged Equity (688) Industrials Sector (369) Global Multisector JNL/JPMorgan JNL/Mellon Bond (348) MidCap Growth (101) Information Technology JNL/Franklin Templeton JNL/JPMorgan Sector (187) Growth Allocation (062) U.S. Government JNL/Mellon JNL/Franklin Templeton & Quality Bond (109) Tell us how you International Index (129) Income want your (075) JNL/Lazard JNL/Mellon annuity JNL/Franklin Templeton International Materials Sector (370) Premiums International Strategic Equity (630) JNL/Mellon invested.
Whole Small Cap (250) percentages JNL/Loomis Sayles MSCI KLD 400 only. TOTAL JNL/Goldman Sachs 4 Global Growth (689) Social Index (667) ALLOCATION (292) JNL/Lord Abbett JNL/Mellon MUST EQUAL JNL/Goldman Sachs Short Duration MSCI World Index (183) 100%. Competitive Income (709) JNL/Mellon Advantage (274) JNL/Mellon Nasdaq 100 Index (222) JNL/Goldman Sachs Bond Index (133) JNL/Mellon Dividend Income JNL/Mellon Real Estate Sector (371) & Growth (278) Communication Services JNL/Mellon JNL/Goldman Sachs Sector (191) S&P 400 MidCap International 5 (654) JNL/Mellon Index (124) JNL/Goldman Sachs Consumer Discretionary JNL/Mellon Intrinsic Value (279) Sector (185) S&P 500 Index (123) JNL/Goldman Sachs JNL/Mellon JNL/Mellon Total Yield (280) Consumer Staples Small Cap Index (128) JNL/GQG Sector (368) JNL/Mellon Emerging Markets JNL/Mellon Utilities Sector (635) Equity (675) Dow Index (145) JNL/Harris
Oakmark JNL/Mellon Global Equity (656) Emerging Markets JNL/Heitman Index (349) PREMIUM ALLOCATIONS U.S. Focused JNL/Mellon Real Estate (687) Energy Sector (190) CONTINUED ON PAGE 7. JNL/Invesco JNL/Mellon Diversified Dividend (365) Equity Income (606) JNL/Invesco JNL/Mellon Global Real Estate (206) Financial Sector (189) JNL/Invesco International Growth (113) JNL/Invesco Small Cap Growth (195) NVDA 785 04/19 Page 6 of 11 NV785 04/20
Premium Allocation (continued from pages 5 and 6) JNL/MFS JNL/T. Rowe Price JNL/WCM Tell us how you Mid Cap Value (207) Balanced (647) Focused International want your Equity (640) annuity JNL/Morningstar JNL/T. Rowe Price Premiums Wide Moat Index (690) Capital Appreciation (637) JNL/Westchester Capital invested. Whole JNL/Neuberger Berman JNL/T. Rowe Price Event Driven (658) percentages Commodity Strategy (643) Established Growth (111) JNL/WMC Balanced only. TOTAL (104) ALLOCATION JNL/Neuberger Berman JNL/T. Rowe Price MUST EQUAL Strategic Income (361) Short-Term Bond (076) JNL/WMC 100%. Government JNL/PIMCO JNL/T. Rowe Price (107) Income (372) U.S. High Yield (660) Money Market JNL/PIMCO JNL/T. Rowe Price Total number Investment Grade Value (149) of allocation Credit Bond (604) JNL/Vanguard selections may JNL/PIMCO Capital Growth (373) not exceed 99. Real Return (078) JNL/Vanguard JNL/PPM
America Equity Income (374) Floating Rate Income (346) JNL/Vanguard JNL/PPM America Global Bond High Yield Bond (136) Market Index (671) JNL/PPM America JNL/Vanguard Total Return (662) Growth ETF JNL/RAFI Allocation (674) Fundamental JNL/Vanguard Asia Developed (298) International (375) JNL/RAFI JNL/Vanguard Fundamental International Europe (299) Stock Market Index (670) JNL/RAFI JNL/Vanguard Fundamental Moderate U.S. Small Cap (702) ETF Allocation (672) JNL/RAFI JNL/Vanguard Multi-Factor Moderate Growth U.S. Equity (703) ETF Allocation (673) JNL/Vanguard U.S. Stock Market Index (668) NVDA 785 04/19 Page 7 of 11 NV785 04/20
Systematic Investment (periodic premium reallocation programs) Only the Please read the Important Information related to Systematic Investments in the Notice to Applicant section on page 9. Investment Division(s) as Automatic Rebalancing. selected in the I elect Automatic Rebalancing of the Investment Divisions according to the allocations in the Premium Allocation Premium Allocation section using the frequency and start date below. If both frequency and start date are left blank, Automatic section can Rebalancing will not be established. participate in Automatic Frequency: Monthly Quarterly Semiannually Annually Rebalancing. Other Systematic Start Date (mm/dd/yyyy): OR Immediately after issue Investment Options may be Note: If no start date is selected, the program will begin one month/quarter/half-year/year (depending on the available. frequency you select) from the date Jackson of NY applies the initial Premium
payment. If no frequency is selected, Please see Systematic the frequency will be annual. If the start date indicated is on day 29, 30, or 31 of a month, but the frequency at Investment which the transfer will occur does not always include this date, Jackson of NY will default the start date and all form (NV5485). subsequent transfer dates to the 28th. If funds are received after the designated start date, the program will begin one frequency from the designated start date. Telephone/Electronic Authorization If no election By checking " Yes," I (we) authorize Jackson of NY to accept instructions to initiate or discontinue Systematic is made, Investment options (Rebalancing, Dollar Cost Averaging, Earnings Sweep) or transfer contract values between Jackson of NY investment options via telephone, internet, or other electronic medium from me, or in the case of Joint Owners, will default to from any Joint Owner, or from my (our) Financial Professional,
subject to Jackson of NY's administrative procedures. " No." Do you consent to Telephone/Electronic Transfer Authorization? Yes No This Jackson of NY has administrative procedures that are designed to provide reasonable assurances that authorization telephone/electronic authorizations are genuine. If Jackson of NY fails to employ such procedures, it may be held is not extended liable for losses resulting from a failure to use such procedures. I (We) release Jackson of NY, its affiliates, to Authorized subsidiaries, and advisors from all damages related in any way to its acting upon any unauthorized Callers. telephone/electronic instruction. I (We) understand and agree that Jackson of NY reserves the right to terminate or modify these telephone/electronic privileges at any time, without cause and without notice to me (us). To give consent to initiate partial withdrawals via telephone, internet, or other electronic medium, please complete the Telephone/Electronic
Authorization Request form (NV3982). Authorized Caller This If you want to authorize an individual other than your Financial Professional to receive Contract information via authorization telephone and/or in writing, please list that individual's information here. is not extended to Telephone/ First Name Middle Name Last Name Electronic Authorization. Social Security Number Date of Birth (mm/dd/yyyy) NVDA 785 04/19 Page 8 of 11 NV785 04/20
Electronic Delivery Authorization If no election is Do you consent to Electronic made, Jackson Delivery of Documents? Yes No of NY will default to Check the box(es) next to the types of documents you wish to receive electronically. If Electronic " No." Delivery is authorized, but no document type is selected, the selection will default to "All Documents." Selection of ALL DOCUMENTS Prospectuses and prospectus supplements Annual and Semiannual reports "ALL DOCUMENTS" Transaction confirmations Other Contract-related correspondence currently excludes quarterly My email address is: statements and tax documents. I (We) will notify the company of any new email address. Please provide This consent will continue until revoked and will cover delivery to you in the form of an email or by notice to you of one email a document's availability on Jackson of NY's website. For jointly owned contracts, all Joint
Owners are consenting to address and electronic delivery and use of the single email address above. Please contact the appropriate Jackson of NY Service print clearly. Center or go to www.jackson.com to update your email address, revoke your consent to electronic delivery or request paper copies. Certain types of correspondence may continue to be delivered by the United States Postal Service for compliance reasons. Registration on Jackson of NY's website (www.jackson.com) is required for If you authorize Electronic electronic delivery of Contract-related correspondence. Delivery but do The computer hardware and software requirements that are necessary to receive, process and retain electronic not provide an communications that are subject to this consent are as follows: To
view and download material electronically, you email address must have a computer with internet access, an active email account and Adobe Acrobat Reader. If you don't or the address is illegible, already have Adobe Acrobat Reader, you can download it free from www.adobe.com. Electronic There is no charge for electronic delivery of electronic communications, although you may incur the costs of internet Delivery will access and of such computer and related hardware and software as may be necessary for you to receive, process not be initiated. and retain electronic documents and communications from Jackson of NY. Please make certain you have given Jackson of NY a current email address. Also let Jackson of NY know if that email address changes. We may need to notify you of a document's availability through email. You may request paper copies, whether or not you consent or revoke
your consent for electronic delivery, at any time and for no charge. Even if you have given us consent, we are not required to make electronic delivery and we have the right to deliver any documents or communications in paper form. Notice to Applicant This application will be attached to and made part of the Contract. Important Information related to Systematic Investments: Systematic Investing does not ensure a profit or protect against loss. Principal value and investment return of the Investment Divisions will fluctuate with changes in market conditions. When redeemed, unit values may be more or less than the original purchase price. Please see the prospectus for additional information related to Systematic Investment options. NVDA 785 04/19 Page 9 of 11 NV785 04/20
Client Acknowledgments 1. I (We) hereby represent to the best of my (our) knowledge and belief that each of the statements and answers contained in this application 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) certify that the date of birth of the Owner and any Joint Owner, primary spousal Beneficiary, Annuitant, or Joint Annuitant, if applicable, stated in this application is (are) true and correctly recorded. 4. I (We) understand that annuity benefits, death benefit values, and withdrawal values, if any, when based on the investment experience of an Investment Division in the separate account of Jackson of NY, are variable and may be increased or decreased, and the dollar amounts are not guaranteed. 5. I (We) have been given a current prospectus for this variable annuity and for each available Investment Division. 6.
To the best of my (our) knowledge and belief the Contract I (we) have applied for is suitable for my (our) insurance and investment objectives, financial situation and needs. 7. 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. 8. I (We) understand that Jackson of NY issues other annuities with similar features, benefits, limitations and charges. I (We) have discussed the alternatives with my (our) financial advisor. 9. I acknowledge and represent that I have executed this application, and that my signature below (including my electronic signature) is my true and valid signature. I further authorize Jackson of NY to accept any electronic signature that I may make to this application. 10. I (We) understand that certain broker-dealers may limit the Investment Divisions, Fixed Account Options, and/or Add-On
Benefits available under the Contract. I (We) have discussed these limitations with my (our) financial professional and have been provided with a list of Investment Divisions, Fixed Account Options and Add-On Benefits currently available for election through my (our) broker-dealer. I (We) understand that any application including an allocation to an Investment Division or Fixed Account Option or election of an Add-On Benefit not available through my (our) broker-dealer will not be accepted. I (We) understand that the Investment Divisions, Fixed Account Options, and/or Add-On Benefits not available through my (our) broker-dealer may be available through other broker-dealers. Client Signatures Owner's Signature Date Signed (mm/dd/yyyy) State where signed It is required for Good Order that all applicable parties to the Owner's Title (required if owned by an Entity) Contract sign here. Joint Owner's Signature Date Signed (mm/dd/yyyy) Required replacement Annuitant's
Signature (if other than Owner) Date Signed (mm/dd/yyyy) State where signed forms must be signed on or before the application Joint Annuitant's Signature (if other than Joint Owner) Date Signed (mm/dd/yyyy) signature date. NVDA 785 04/19 Page 10 of 11 NV785 04/20
Financial Professional Acknowledgments By signing this form, I certify that: 1. I am authorized and qualified to discuss the Contract herein applied for. 2. I have fully explained the Contract to the client, including Contract benefits, restrictions and charges and I believe this transaction is suitable given the client's financial situation and needs. 3. The applicant's statement as to whether or not an existing life insurance policy or annuity contract is being replaced is true and accurate to the best of my knowledge and belief. 4. I have complied with requirements for disclosures and/or replacements as necessary. 5. I have discussed all applicable limitations to Investment Divisions, Fixed Account Options, and/or Add-On Benefit availability with the applicant and have provided the applicant with a list of Investment Divisions, Fixed Account Options, and Add-On Benefits currently available for election. Financial Professional
#1 Signature Date Signed(mm/dd/yyyy) Jackson of NY Assigned ID All Financial Professional certifications, licenses and First Name Middle Name Last Name trainings must be completed prior to Email Address (print clearly) Business Phone Number (include area code) application Extension execution. If more than one Financial Professional is participating on this case, please provide the additional Financial Professional names and Jackson of NY Assigned IDs. Financial Professional Name #2 Jackson of NY Assigned ID Financial Professional Name #3 Jackson of NY Assigned ID Financial Professional Name #4 Jackson of NY Assigned ID Not FDIC/NCUA Insured Not Bank/CU guaranteed May lose value Not a deposit Not insured by any federal agency NVDA 785 04/19 Page 11 of 11 NV785 04/20
