Contract Schedule 

        


  

  

  	
          Owner: 

        	
          [John Doe]

        	
          Contract Number:  

        	
          [687456]

        
	
          [Joint Owner:  

        	
          [Jane Doe]]

        	
          Issue Date:  

        	
          [04/15/23]

        
	
          Annuitant:  

        	
          [John Doe]

        	
          Scheduled Annuity Date:

        	
          [04/01/65]

        
	
          Determining Life (Lives):

        	
          [John Doe]

        	
          Maximum Issue Age:

        	
          [80]

        
	 	
          [Jane Doe]

        	 	 


  

  

  Purchase Payments

  	
          Initial Purchase Payment:

        	
          $[10,000.00]

        
	
          Minimum Additional Purchase Payment:  

        	
          $[50.00]

        
	
          Maximum Total Purchase Payments:

        	
          $[1 million]

        


  

  

  Transfers

  	
          Number of Free Transfers Permitted:  

        	
          [12] each Contract Year

        
	
          Transfer Fee:  

        	
          $25.00 for each transfer in excess of the free transfers permitted

        
	
          Transfer Index Anniversary:

        	
          Every Index Anniversary

        


  

  

  Contract Charges

  	
          Mortality and Expense Risk Charge:

        	
          [1.25]% of the Variable Options’ net asset value

        
	
          Contract Maintenance Charge:  

        	
          $[50.00] each Contract Year

        
	
          Designated Amount:  

        	
          Contract Value must be $[100,000.00] to waive the Contract Maintenance Charge

        


  

  

  Withdrawals

  	
          Minimum Partial Withdrawal: 

        	
          $[100.00]

        
	
          Minimum Required Value:  

        	
          $[2,000.00]

        
	
          Free Withdrawal Amount:

        	
          [10]% of total Purchase Payments

        


  

  

  Withdrawal Charge Percentages Table

  

  

  	 	
          Number of Complete Years Since Receipt of Purchase Payment

        	
          Charge

        	 	 	 	 
	 	 	 	 	 	 	
          0

        	
          8%

        
	 	 	 	 	 	 	
          1

        	
          7%

        
	 	 	 	 	 	 	
          2

        	
          6%

        
	 	 	 	 	 	 	
          3

        	
          5%

        
	 	 	 	 	 	 	
          4

        	
          3%

        
	 	 	 	 	 	 	
          5

        	
          1%

        
	
          6 years or more

        	
          0%

        	 	 	 


  

  

  Annuity Payments

  	
          Minimum Annuity Payment:

        	
          $[100.00]

        
	
          Annuity Mortality Table:

        	
          2012 ALB Individual Annuity Reserve Table

        
	
          Minimum Annual Annuity Payment Rate:

        	
          1.00%

        
	
          Allowed Payees:

        	
          [Financial institution, qualified plan, court-ordered individual]

        


  

  

  
    
      S40875-NY02    3        

    

    
      


    

  

  Guaranteed Purchase Rate Table

  The tables below are examples of Guaranteed Purchase Rates for a representative set of Ages, using the Age of the Annuitant on the Annuity Date based on
    their most recent birthday, in certain calendar years.  Guaranteed Purchase Rates are based on the Annuity Mortality Table and Minimum Annual Annuity Payment Rate shown in the Annuity Payments section of the Contract Schedule.  Guaranteed Purchase
    Rates will vary by Age on Annuity Date, annuity option, and the calendar year in which Annuity Payments begin.  

  

  

  The Guaranteed Purchase Rates shown below are only applicable if Annuity Payments begin for the designated Age on Annuity Date in the designated calendar
    year.

  

  

  Guaranteed Purchase Rates change based on the calendar year in which annuitization occurs. 

  Upon request, we will furnish rates for Ages and guaranteed periods not shown.

  	
          OPTION 1: LIFE ANNUITY

        
	
          Monthly installments per $1,000 payable while the Annuitant is living

        
	
           

        	
          Guaranteed Rates for 2025

        	
          Guaranteed Rates for 2035

        	
          Guaranteed Rates for 2045

        
	
          Age of Annuitant on Annuity Date

        	
          Male Annuitant

        	
          Female Annuitant

        	
          Male Annuitant

        	
          Female Annuitant

        	
          Male Annuitant

        	
          Female Annuitant

        
	
          60

        	
          $3.36

        	
          3.20

        	
          3.27

        	
          3.14

        	
          3.19

        	
          3.08

        
	
          70

        	
          4.72

        	
          4.42

        	
          4.56

        	
          4.31

        	
          4.42

        	
          4.20

        
	
          80

        	
          7.75

        	
          7.06

        	
          7.44

        	
          6.84

        	
          7.16

        	
          6.64

        


  

  

  	
          OPTION 2: LIFE ANNUITY WITH A GUARANTEED PERIOD - Male Annuitant

        
	
          Monthly installments per $1,000, payable for the 

        
	
          guaranteed period and thereafter while the Annuitant is living

        
	
           

        	
          Guaranteed Rates for 2025

        	
          Guaranteed Rates for 2035

        	
          Guaranteed Rates for 2045

        
	
          Age of Annuitant on Annuity Date 

        	
          Guaranteed Period

        	
          Guaranteed Period

        	
          Guaranteed Period

        
	
          10 years

        	
          20 years

        	
          10 years

        	
          20 years

        	
          10 years

        	
          20 years

        
	
          60

        	
          $3.32

        	
          3.20

        	
          3.24

        	
          3.14

        	
          3.17

        	
          3.09

        
	
          70

        	
          4.57

        	
          4.04

        	
          4.44

        	
          3.98

        	
          4.32

        	
          3.93

        
	
          80

        	
          6.68

        	
          4.54

        	
          6.54

        	
          4.53

        	
          6.40

        	
          4.52

        
	 	 	 	 	 	 	 
	
          OPTION 2: LIFE ANNUITY WITH A GUARANTEED PERIOD - Female Annuitant

        
	
          Monthly installments per $1,000, payable for the 

        
	
          guaranteed period and thereafter while the Annuitant is living

        
	
           

        	
          Guaranteed Rates for 2025

        	
          Guaranteed Rates for 2035

        	
          Guaranteed Rates for 2045

        
	
          Age of Annuitant on Annuity Date

        	
          Guaranteed Period

        	
          Guaranteed Period

        	
          Guaranteed Period

        
	
          10 years

        	
          20 years

        	
          10 years

        	
          20 years

        	
          10 years

        	
          20 years

        
	
          60

        	
          $3.18

        	
          3.09

        	
          3.12

        	
          3.04

        	
          3.06

        	
          3.00

        
	
          70

        	
          4.32

        	
          3.91

        	
          4.22

        	
          3.86

        	
          4.13

        	
          3.82

        
	
          80

        	
          6.30

        	
          4.50

        	
          6.18

        	
          4.49

        	
          6.07

        	
          4.48

        


  
    
      S40875-NY02    3A      

    

    
      


    

  

  

  

  	
          OPTION 3: JOINT AND SURVIVOR ANNUITY

        
	
          Monthly installments per $1,000, payable while either annuitant is living

        
	
          Age of Annuitant on Annuity Date

        	
          Guaranteed Rates for 2025

        	
          Guaranteed Rates for 2035

        	
          Guaranteed Rates for 2045

        
	
          Age of Annuitant on Annuity Date

        	
          Age of Annuitant on Annuity Date

        	
          Age of Annuitant on Annuity Date

        
	
          60

        	
          70

        	
          80

        	
          60

        	
          70

        	
          80

        	
          60

        	
          70

        	
          80

        
	
          60

        	
          $2.81

        	
          3.12

        	
          3.28

        	
          2.77

        	
          3.06

        	
          3.20

        	
          2.73

        	
          3.00

        	
          3.13

        
	
          70

        	
          3.05

        	
          3.76

        	
          4.35

        	
          3.00

        	
          3.68

        	
          4.24

        	
          2.95

        	
          3.61

        	
          4.13

        
	
          80

        	
          3.16

        	
          4.20

        	
          5.74

        	
          3.09

        	
          4.10

        	
          5.58

        	
          3.04

        	
          4.02

        	
          5.43

        


  

  

  	
          OPTION 4: JOINT AND SURVIVOR WITH A GUARANTEED PERIOD

        
	
          Monthly installments per $1,000, payable for a guaranteed period and thereafter while both Annuitants are living. 10 year guaranteed period.

        
	
          Age of Annuitant on Annuity Date

        	
          Guaranteed Rates for 2025

        	
          Guaranteed Rates for 2035

        	
          Guaranteed Rates for 2045

        
	
           

          Age of Annuitant on Annuity Date

        	
          Age of Annuitant on Annuity Date

        	
          Age of Annuitant on Annuity Date

        
	
          60

        	
          70

        	
          80

        	
          60

        	
          70

        	
          80

        	
          60

        	
          70

        	
          80

        
	
          60

        	
          $2.81

        	
          3.12

        	
          3.27

        	
          2.77

        	
          3.06

        	
          3.19

        	
          2.73

        	
          3.00

        	
          3.12

        
	
          70

        	
          3.04

        	
          3.75

        	
          4.32

        	
          2.99

        	
          3.67

        	
          4.21

        	
          2.94

        	
          3.60

        	
          4.11

        
	
          80

        	
          3.13

        	
          4.15

        	
          5.55

        	
          3.07

        	
          4.06

        	
          5.43

        	
          3.02

        	
          3.98

        	
          5.31

        


  

  

  	
          OPTION 5: REFUND LIFE ANNUITY

        
	
          Monthly installments per $1,000 payable while the Annuitant is living

        
	
           

        	
          Guaranteed Rates for 2025

        	
          Guaranteed Rates for 2035

        	
          Guaranteed Rates for 2045

        
	
          Age of Annuitant on Annuity Date

        	
          Male Annuitant

        	
          Female Annuitant

        	
          Male Annuitant

        	
          Female Annuitant

        	
          Male Annuitant

        	
          Female Annuitant

        
	
          60

        	
          $2.99

        	
          2.90

        	
          2.95

        	
          2.87

        	
          2.91

        	
          2.84

        
	
          70

        	
          3.88

        	
          3.71

        	
          3.82

        	
          3.66

        	
          3.76

        	
          3.62

        
	
          80

        	
          5.42

        	
          5.09

        	
          5.33

        	
          5.02

        	
          5.24

        	
          4.96

        


  

  

  
    
      S40875-NY02  3B

    

    
      


    

  

  

  

  	
          Allocation Options Contract Schedule

        


  

  

  	
          Owner: 

        	
          [John Doe]

        	
          Contract Number:  

        	
          [687456]

        
	
          [Joint Owner:  

        	
          [Jane Doe]]

        	
          Issue Date:  

        	
          [04/15/23]

        
	
          Annuitant:  

        	
          [John Doe]

        	
          Scheduled Annuity Date:

        	
          [04/15/65]

        


  

  

  Allocation Guidelines:  

  1.  Allocations must be made in whole percentages.

  

  

  Variable Options:

  Variable Account:    [Allianz Life® of NY Variable Account C] 

  

  

  [AZL® Government Money Market Fund

  AZL® MVP Balanced Index Strategy Fund

  AZL® MVP Growth Index Strategy Fund]

  

  

  Index Options:

  Index Account:     [Separate Account IANY]

  

  

  Index Availability Period:
    [The period of time beginning on the Issue Date and ending on the day before the [sixth] Index Anniversary]

  

  

  This contract contains a provision allowing us to make an Index Option temporarily unavailable on the upcoming Term Start Date if, due to
    yield on investments or the availability or cost of hedging, we are unable to support the Minimum Cap on that Index Option.

  

  

  Index Performance Strategy Index Options

  	
          Index

        	
          Buffer for all Terms

        	
           

          Minimum Cap for all Terms

           

        	
           

          Term

           

        
	
          [S&P 500® Index

        	
          [10.00]%

        	
          [6.25]%

        	
          [1 Index Year]]

        
	
          [Nasdaq-100® Index

        	
          [10.00]%

        	
          [6.25]%

        	
          [1 Index Year]]

        
	
          [Russell 2000® Index

        	
          [10.00]%

        	
          [6.25]%

        	
          [1 Index Year]]

        
	
          [EURO STOXX 50®

        	
          [10.00]%

        	
          [6.25]%

        	
          [1 Index Year]]

        


  

  

  
    
      S40876-NY03

    

    
      


    

  

  

  

  

  

  	
          Allocation Options Contract Schedule continued from previous page 

        


  Index Performance Strategy Index Options

  	
          Index

        	
          Buffer for all Terms

        	
           

          Minimum Cap for all Terms

           

        	
           

          Minimum Participation Rate for all Terms 

           

        	
           

          Term

           

        
	
          [S&P 500® Index

        	
          [10.00]%

        	
          [18.75]%

        	
          100.00%

        	
          [3 Index Years]]

        
	
          [Nasdaq-100® Index

        	
          [10.00]%

        	
          [18.75]%

        	
          100.00%

        	
          [3 Index Years]]

        
	
          [Russell 2000® Index

        	
          [10.00]%

        	
          [18.75]%

        	
          100.00%

        	
          [3 Index Years]]

        
	
          [EURO STOXX 50®

        	
          [10.00]%

        	
          [18.75]%

        	
          100.00%

        	
          [3 Index Years]]

        
	
          [S&P 500® Index

        	
          [20.00]%

        	
          [15.75]%

        	
          100.00%

        	
          [3 Index Years]]

        
	
          [Nasdaq-100® Index

        	
          [20.00]%

        	
          [15.75]%

        	
          100.00%

        	
          [3 Index Years]]

        
	
          [Russell 2000® Index

        	
          [20.00]%

        	
          [15.75]%

        	
          100.00%

        	
          [3 Index Years]]

        
	
          [EURO STOXX 50®

        	
          [20.00]%

        	
          [15.75]%

        	
          100.00%

        	
          [3 Index Years]]

        
	
          [S&P 500® Index

        	
          [10.00]%

        	
          [37.50]%

        	
          100.00%

        	
          [6 Index Years]]

        
	
          [Nasdaq-100® Index

        	
          [10.00]%

        	
          [37.50]%

        	
          100.00%

        	
          [6 Index Years]]

        
	
          [Russell 2000® Index

        	
          [10.00]%

        	
          [37.50]%

        	
          100.00%

        	
          [6 Index Years]]

        
	
          [EURO STOXX 50®

        	
          [10.00]%

        	
          [37.50]%

        	
          100.00%

        	
          [6 Index Years]]

        


  
    
      5

      S40876-NY03

    

    
      


    

  

  

  

  

  

  	
          Allocation Options Contract Schedule continued from previous page

        


  

  

  

  

  Index Protection NY Strategy Index Options

  	
          Index

        	
          Buffer for all Index Years

        	
           

          Minimum Cap for all Index Years

           

        	
           

          Term

           

        
	
          [S&P 500®1 Index

        	
          [30.00]%

        	
          [4.25]%

        	
          [1 Index Year]]

        
	
          [Nasdaq-100®2 Index

        	
          [30.00]%

        	
          [4.25]%

        	
          [1 Index Year]]

        
	
          [Russell 2000®3 Index

        	
          [30.00]%

        	
          [4.25]%

        	
          [1 Index Year]]

        
	
          [EURO STOXX 50®4

        	
          [30.00]%

        	
          [4.25]%

        	
          [1 Index Year]]

        


  

  

  
    
      6

      S40876-NY03

    

    
      


    

  

  

  

  

  

  

  

  	
          Allocation Options Contract Schedule continued from previous page

        


  

  

  Index Options That Will Not Be Made Temporarily Unavailable

  	
          Index

        	
           

          Strategy

           

        
	
          [S&P 500® Index

        	
          Index Performance Strategy, 1-year Term, 10% Buffer

        
	
          Nasdaq-100® Index

        	
          Index Performance Strategy, 1-year Term, 10% Buffer

        
	
          Russell 2000® Index

        	
          Index Performance Strategy, 1-year Term, 10% Buffer

        
	
          EURO STOXX 50®

        	
          Index Performance Strategy, 1-year Term, 10% Buffer

        
	
          S&P 500® Index

        	
          Index Performance Strategy, 3-year Term, 10% Buffer 

        
	
          Nasdaq-100® Index

        	
          Index Performance Strategy, 3-year Term, 10% Buffer

        
	
          Russell 2000® Index

        	
          Index Performance Strategy, 3-year Term, 10% Buffer

        
	
          EURO STOXX 50®

        	
          Index Performance Strategy, 3-year Term, 10% Buffer

        
	
          S&P 500® Index

        	
          Index Performance Strategy, 3-year Term, 20% Buffer

        
	
          Nasdaq-100® Index

        	
          Index Performance Strategy, 3-year Term, 20% Buffer

        
	
          Russell 2000® Index

        	
          Index Performance Strategy, 3-year Term, 20% Buffer

        
	
          EURO STOXX 50®

        	
          Index Performance Strategy, 3-year Term, 20% Buffer

        
	
          S&P 500® Index

        	
          Index Performance Strategy, 6 -year Term, 10% Buffer

        
	
          Nasdaq-100® Index

        	
          Index Performance Strategy, 6-year Term, 10% Buffer

        
	
          Russell 2000® Index

        	
          Index Performance Strategy, 6-year Term, 10% Buffer

        
	
          EURO STOXX 50®

        	
          Index Performance Strategy, 6-year Term, 10% Buffer

        
	
          S&P 500® Index

        	
          Index Protection NY Strategy

        
	
          Nasdaq-100® Index

        	
          Index Protection NY Strategy

        
	
          Russell 2000® Index

        	
          Index Protection NY Strategy

        
	
          EURO STOXX 50®

        	
          Index Protection NY Strategy]

        


  
    
      7

      S40876-NY03

    

    
      


    

  

  

  

  	
          Allocation Options Contract Schedule continued from previous page

        


  

  

  

  

  The terms of the license agreements between us and [S&P Dow Jones Indices LLC, Russell Investments, NASDAQ OMX Group Inc. and STOXX Limited] of the
    Indices require us to state the following:

  

  

  [S&P® is a registered trademark of Standard & Poor’s Financial Services LLC (“S&P”). This trademark has been licensed for use by
    S&P Dow Jones Indices LLC and its affiliates. S&P® and S&P 500® are trademarks of S&P. These trademarks have been sublicensed for certain purposes by Allianz Life Insurance Company of New York (“Allianz Life of
    NY”). The S&P 500 is a product of S&P Dow Jones Indices LLC and/or its affiliates and has been licensed for use by Allianz Life of NY. Allianz Life of NY products are not sponsored, endorsed, sold, or promoted by S&P Dow Jones Indices LLC,
    Dow Jones, S&P, or their respective affiliates and neither S&P Dow Jones Indices LLC, Dow Jones, S&P, or their respective affiliates make any representation regarding the advisability of investing in such product.]

  

  

  [The NASDAQ-100 Index® includes 100 of the largest domestic and international non-financial securities listed on The NASDAQ Stock Market, based
    on capitalization. The NASDAQ-100®, NASDAQ-100 Index®, NASDAQ®, and OMX® are registered trademarks of NASDAQ OMX Group, Inc. (which with its affiliates are the Corporations) and are licensed for use by
    Allianz Life Insurance Company of New York. The product(s) have not been passed on by the Corporations as to their legality or suitability. The product(s) are not issued, endorsed, sold, or promoted by the Corporations. THE CORPORATIONS MAKE NO WARRANTIES AND BEAR NO LIABILITY WITH RESPECT TO THE PRODUCT(S).]

  

  

  [The Russell 2000® is a trademark of Russell Investments and has been licensed for use by Allianz Life Insurance Company of New York.  Allianz
    products are not sponsored, endorsed, sold or promoted by Russell Investments and Russell Investments makes no representation regarding the advisability of investing in Allianz products.]

  

  

  [The EURO STOXX  50®  is the intellectual property (including registered trademarks) of STOXX Limited, Zurich, Switzerland.  The product based on
    the Index is in no way sponsored, endorsed, sold or promoted by STOXX and shall not have any liability with respect thereto.]

  

  

  
    
      8

      S40876-NY03

    

    
      


    

  

  LIST OF FUNDS

  

  

  Allianz Life Insurance Company of New York

  S40876-NY03

  

  

  February 8, 2022

  

  

  The list of available investment options may change.  Any change in options will be submitted for informational purposes in a revised List of Funds.

  

  

  Policy form to be used with:  S40876-NY03

  	
          Variable Options

        
	
          AZL® MVP Balanced Index Strategy Fund

        	
          AZL® Government Money Market Fund

        
	
          AZL® MVP Growth Index Strategy Fund

        	 
	 	 


  

  

  

  

  
    9

    S40876-NY03