8069 (05/2021) 2
My payment preferences
By 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. This arrangement does not change the premium due date specified 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 year.
I/We 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. Such notifications 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 (if
Policy owner signature (Required) Name (Print) applicable) Date
X
Title (if
Policy owner signature (Required) Name (Print) applicable) Date
X
Your 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 YEAR
Address No PO boxes please
STREET APT. CITY S TAT E ZIP
STEP 5B Please only complete if the bank account holder named above (the payer) is not the policy owner.
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
X
X
Payer type
If you are one of these Designated Payer types,
please check the appropriate box and sign below.
▫
Individual
▫
Corporation
▫
Trust
▫
Partnership
▫
Sole-proprietor
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partners other than the insured. Titles are required.
By mail: New York Life, PO Box 130539, Dallas, TX 75313-0539
By fax: (800) 278-4117
In 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 newyorklife.com/register. 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
