My payment preferences Manage your account ... - New York …

1 8069 (05/2021) 1 My payment preferences STEP 1 Tell us your contact Check this box to update our records with new address information. STREET APT. CITY S TAT E ZIPD aytime phone Email FIRST LASTOne-Time payment Complete all steps below except Step 4. Authorize a one-time electronic funds transfer (EFT) for initial payment , catch up premiums or a renewal payment amount for one time payments* Payments drawn monthly*If selecting recurring payments for Auto-Adjusted Billing, please note that the premium payment is subject to change on your policy anniversary. You will receive notice of this change on or around your policy anniversary.

2 If, at any time, you would like to rescind this authorization, you may call us at new york life Guaranteed Future Income annuity or new york life Future Mutual Income annuity ONLYP ayments to be drawn: Monthly Quarterly Semi-annually Annually STEP 2 payment AuthorizationYour signature is required on the next page NameAddressCity, State, ZipPAY TO THEORDER OFDOLLARSBANK NAMEADDRESSCIT Y, STATE, ZIPFOR123401-2345678 DateSAMPLE$ 0001234567891234 Bank Routing NumberAccount NumberCheckNumber: 123456789:123456789000123456789 Routing numberBank name City, State of branch account number Name of account holder Checking SavingsSTEP 5A Te l l u s w h a t bank account you d like to use (must be a bank account ).

3 Save time and paper. Manage your account online at Policy owner name - Individual/Trust/Corporation Policy numbers $$$ $$$ Option to purchase paid-up additions-OPP ($10 minimum, $5 for Employee Whole life ) Add to existing multiple arrangementCase Ref # Premium amount STEP 3 Tell us your policy number(s) and premium draft amount(s). For additional policies, please list on bottom of page 2. For Whole life , Term, and Universal life insurance policies: Withdraw premiums for each policy as individual transactions each month on the policy due date. Withdraw premiums for all policies in a single transaction on the 15TH of each month.

4 For Variable Universal life insurance policies and all annuity policies: Withdraw premiums for each policy as individual transactions each month on the policy due date. Select a draft date to withdraw all premiums as individual transactions. (cannot be scheduled for the 29th, 30th, or 31st of month). Draft date: For new york life Guaranteed Future Income annuity / new york life Future Mutual Income annuity policies ONLY: Indicate automatic payment end date (cannot be scheduled for the 29th, 30th, or 31st of month) Please indicate day of the month MM/DD/YYYY STEP 4 Select your draft date (recurring payments only).

5 8069 0521 018069 (05/2021) 2 My payment preferencesBy signing, I/We authorize new york life Insurance Company, new york life Insurance and annuity Corporation and NYLIFE Insurance Company of Arizona (collectively, new york life ) to pay policy premiums and/or purchase paid-up additions by withdrawing them from the account listed in Step 5A above and to make refunds to that account . I/We also authorize the bank associated with that ac-count to debit and/or credit that account accordingly. I/We understand that for recurring payments, the withdrawals will normally be debited monthly on a regular schedule established by new york life .

6 This arrangement does not change the premium due date specif ied in the policy and will not extend any applicable grace or late periods for premium payment ; the policy will lapse at the end of any applicable grace or late periods if the premium remains unpaid; and premium notices will not be sent while this arrangement is in effect. For life products issued by new york life Insurance Company or NYLIFE Insurance Company of Arizona, the total amount of your annual premium will be greater using recurring automatic bank drafts than if you paid your premium once each also understand that the policy owner or the bank account holder may terminate or modify this arrangement at any time by notifying new york life at least 10 days prior to the withdrawal date.

7 Such notif ications must be made by calling new york life , or sending a signed and dated request to the address on this form. STEP 6A Read and sign. Title (ifPolicy owner signature (Required) Name (Print) applicable) Date X Title (ifPolicy owner signature (Required) Name (Print) applicable) Date XYour signature(s) confirm(s) that you have read all the information on this form and that the information you have provided is correct. Social Security or Tax ID number Date of birth Relationship to policy owner MONTH DAY YE ARAddress No PO boxes please STREET APT. CITY S TAT E ZIPSTEP 5B Please only complete if the bank account holder named above (the payer) is not the policy owner.

8 Helpful tip: provide the Designated Payer s information below and indicate payer type in the signature section below. STEP 6B Please only complete if you are a Designated Payer. Bank account owner signature Title (if (Required if other than the policy owner) Name (Print) applicable) Date Bank account owner signature Title (if (Required if other than the policy owner) Name (Print) applicable) Date XXPayer type If you are one of these Designated Payer types,please check the appropriate box and sign below. Individual Corporation Trust Partnership Sole-proprietor ,I WKH RZQHU RU SD\HU LV D FRUSRUDWLRQ WUXVW RU SDUWQHUVKLS SOHDVH SURYLGH VLJQDWXUHV RI WZR FRUSRUDWH R FHUV UHTXLUHG WUXVWHHV RU WZR partners other than the insured.

9 Titles are mail: new york life , PO Box 130539, Dallas, TX 75313-0539 By fax: (800) 278-4117In person: You can drop off this completed form at a new york life office near you. Questions? Call us at 1-800-CALL-NYL ONLINE: Save time and postage by uploading this form at Log in or register to upload in minutes. You have options. Pick one that best suits your needs. STEP 7 Done! Send us your completed form. If you have additional instructions or comments, tell us below. We ll reach out to you if we need more information. 8069 0521 02