Required Forms for New Business

Secure Term Fixed Annuity V

Financial Advisors: please check with your firm to determine if suitability forms are needed. 

Required Forms for all Annuity New Business
Required Forms for Applicable Tax Scenarios
Materials to be Left with the Proposed Insured

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Required Annuity New Business Forms

Form Name
Description
Form Number

Application Packet

 1

Consists of instructions, application and producer’s statement. Must be completed and submitted.

 1

Based on jurisdiction.
To find the correct packet, filter by state on our Literature page.

 1

Application Packet

 1

Consists of instructions, application and producer’s statement. Must be completed and submitted(applies to all states except AL, CA, DE, FL, GU, ND, NY, SD).

 1

STV-APP

 1

Application Packet

 1

Consists of instructions, application and producer’s statement. Must be completed and submitted(applies to AL).

 1

STV-APP-AL

 1

Application Packet

 1

Consists of instructions, application and producer’s statement. Must be completed and submitted(applies to DE, GU, ND, SD).

 1

STV-NOCAPP

 1

Application Packet

 1

Consists of instructions, application and producer’s statement. Must be completed and submitted(applies to CA).

 1

STV-NOCAPP-CA

 1

Application Packet

 1

Consists of instructions, application and producer’s statement. Must be completed and submitted(applies to FL).

 1

STV-NOCAPP-FL

 1

Application Packet

 1

Consists of instructions, application and producer’s statement. Must be completed and submitted(applies to NY).

 1

STV-NOCAPP-NY

 1

NAIC Replacement Form

 1

Must be completed and submitted with the application. Follow state replacement regulations and check for any form specific to your state. For New York, complete the NY Definition of Replacement and the NY Regulation 60 Kit. 

 1

ANN22190

 1

Important Notice to Military Servicemembers and their Dependents

 1

Must be completed and submitted for Florida residents only.

1

GEN-MILIFORM

 1

.

Required Only for Applicable Tax Classifications and Scenarios Below

Form Name
Description
Form Number

Roth IRA Acknowledgement

 1

Must be completed for Roth IRA purchased using new money and attached to the application.

 1

ANN19001

 1

1035 Exchange Form

 1

Use when the proceeds are an exchange.

 1

ANN43263F

 1

Certificate of Deposit/Mutual Fund Redemption and Transfer Form

 1

Use when the proceeds are part of a transfer.

 1

ANN43036F

 1

Transfer/Direct Rollover Form

 1

Use when the proceeds are a qualified transfer or rollover.

 1

ANN43009FNS

 1

Inherited IRA Information/Transfer

 1

Use for Inherited Individual Retirement Annuity Account (IRA) Transfers.

 1

ANN18752

 1

Inherited IRA Information Disclosure Statement

 1

Use for Inherited Individual Retirement Annuity Account (IRA) Transfers.

 1

ANN18753

 1

External Roth IRA Conversion Form

 1

Use when requesting a full or partial conversion from an eligible retirement plan held by an external financial institution to a new NYLIAC Roth IRA.

 1

ANN18738

 1

Internal NYLIAC Annuity Roth IRA Conversion Form

 1

Use when requesting a full or partial conversion from an internal qualified NYLIAC annuity policy to a new NYLIAC Roth IRA annuity policy.

 1

ANN18739C

 1

72(u) Disclosure Form

 1

Complete for trust or entity-owned annuity policies.

 1

19070

 1

Statement of Trust

 1

Complete for trust-owned annuity policies.

 1

19072

 1

.

Materials to be Left with the Proposed Insured

Form Name
Description
Form Number

NYL Privacy Information

 1

Must be left with client. Important Information about Procedures for Opening A New Account.

 1

ANN43088

 1

Buyer’s Guide for Deferred Annuities

 1

Must be left with client. Only applicable to specific states.

 1

18229 or 19008
(Based on jurisdiction)

 1

Secure Term V Contract Summary

 1

Must be left with client. Check for any form specific to your state. 

 1

CS18D-001
(Note: certain states, including AR, ID, NJ, NY and WI, require specific forms.)

 1

EBB Disclosure Form

 1

Must be left with client.

 1

ANN18754

 1

To view all available forms, visit the Literature search.