Agent or Registered Representative Assignment Request Form

**SCHEMA ATTACHED**

New York Life Insurance Company (NYLIC) New York Life Insurance and Annuity Corporation (A Delaware Corporation) (NYLIAC) NYLIFE Insurance Company of Arizona (Not licensed in every state)(NYLAZ)

Agent or Registered Representative Assignment Request Form

General Office:

Policy Number(s):

Insured/Annuitant: First Name

Owner:

(If other than insured)

First Name

Middle Initial Middle Initial

Last Name Last Name

Owner's Phone:

Home: ( ) Business: ( )

Best time to call Best time to call

AM/PM AM/PM

Please assign agent (please print name) as servicing agent, and if also a registered representative of NYLIFE Securities LLC., as a registered representative on the policy number(s) above. The assignment of a variable product policy must be to a Registered Representative of NYLIFE Securities, LLC. This request replaces all previous requests.

Agent/Registered Representative's Code:

G.O. Code:

/ / Date

/ / Date

X Owner's Signature (Not required if agent meets Permanent Servicing Criteria on page 2.)

X Other Required Signature

Additional business written in the household: Policy Number(s):

Please select one assignment request: Temporary Servicing Agent or Permanent Servicing Agent: 21134GO (11/14) Page 1 of 2

 Temporary Servicing Agent Request

To qualify as a Temporary Servicing Agent (TSA), please have the client sign the Form 21134GO (cannot be solicited by mail), and return to your General Office for processing. Please note, a TSA assignment will expire after 24 months if the TSA does not meet additional criteria required to become a Permanent Servicing Agent. No new paperwork is needed to extend a TSA, if the Managing Partner approves. A TSA assignment can be revoked at any time at the discretion of the Managing Partner. TSA assignments are not available for variable products, LTC, fixed annuities, or BOLI/COLI.

Criteria Client requires service work and has no active agent

Required Documentation Form 21134GO

Permanent Servicing Agent Request

To qualify as a Permanent Servicing Agent (PSA), please select one of the following criteria and submit the required documentation:

Criteria

Sale to existing household An increase or decrease in face amount An increase or decrease in premium, including adding an OPP rider Adding, removing, or exercising a rider Completing a Transfer or Interest Sweep Change in future allocation or automatic reallocation

for a variable annuity or variable life policyholder

Changing a beneficiary Delivering a death claim to a member of the household Processing a waiver of premium for a member of the household Processing a transfer of ownership

Required Documentation First page of application First page of application First page of application First page of application Form 18523 or 18485 Form 18485 or 21130

Form 21131 Form 20838A Form 22030 Form 21132

X MP Initials (or proxy)

/ / Date

Variable products are distributed by NYLIFE Distributors LLC, Member FINRA/SIPC and offered though properly licensed registered representatives.

21134GO (11/14) Page 2 of 2

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