ex4b.htm












	
Contract Schedule













	
Owner:

	
[John Doe]

	
Contract Number:

	
[??687456]


	
[Joint Owner:

	
[Jane Doe]]

	
Issue Date:

	
[04/15/10]


	
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 [Sixth] Index Anniversary


	  	  
	
Contract Charges

	  
	
Product Fee:

	
[1.25]%


	
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

	
8.5%


	
1

	
8%


	
2

	
6.5%


	
3

	
5%


	
4

	
3%


	
6 years or more

	
0%


















	
Annuity Payments

	  
	
Minimum Annuity Payment:

	
$[100.00]


	
Annuity Mortality Table:

	
[Annuity 2000 Mortality Table]


	
Minimum Annual Annuity Payment Rate:

	
[1.00]%


	
Allowed Payees:

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



























Guaranteed Purchase Rate Table


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







S40875-NY                                                                               3




  





  











  














	
Annuity Options - Guaranteed monthly annuity payments per $1,000


 


	  	
Option 1

	
Option 2

	
Option 3

	
Option 4

	
Option 5


	  	
Life Annuity

	
Life with 10-year guaranteed period

	
Life with 20-year guaranteed period

	
100% joint and survivor

	
100% joint and survivor with10-year guaranteed period

	
Refund Life Annuity


	
Age on


Annuity Date

	
Male

	
Female

	
Male

	
Female

	
Male

	
Female

	
Male & Female


Same Age

	
Male & Female


Same Age

	
Male

	
Female


	
30

	
[2.08

	
1.97

	
2.08

	
1.97

	
2.07

	
1.97

	
1.84

	
1.84

	
2.00

	
1.92


	
40

	
2.45

	
2.29

	
2.45

	
2.29

	
2.42

	
2.28

	
2.10

	
2.10

	
2.29

	
2.19


	
50

	
3.02

	
2.78

	
3.00

	
2.77

	
2.92

	
2.73

	
2.49

	
2.49

	
2.70

	
2.57


	
60

	
3.95

	
3.57

	
3.87

	
3.53

	
3.59

	
3.37

	
3.12

	
3.11

	
3.29

	
3.14


	
70

	
5.66

	
5.03

	
5.28

	
4.83

	
4.24

	
4.13

	
4.22

	
4.20

	
4.18

	
4.00


	
80

	
8.93

	
8.09

	
7.07

	
6.79

	
4.55

	
4.53

	
6.37

	
6.04

	
5.54

	
5.38


	
90

	
15.24

	
14.64

	
8.36

	
8.30

	
4.59

	
4.59

	
10.68

	
7.98

	
7.66

	
7.50]

















S40875-NY                                                                               3




  





  






 






  





  











  














	
Allocation Options Contract Schedule













	
Owner:

	
[John Doe]

	
Contract Number:

	
[??687456]


	
[Joint Owner:

	
[Jane Doe]]

	
Issue Date:

	
[04/15/10]


	
Annuitant:

	
[John Doe]

	
Scheduled Annuity Date:

	
[04/15/65]












Allocation Guidelines:


1.  [Currently, you can select up to [3] of the Variable Options.  This number will not decrease after the Issue Date.


2. Currently, you can select up to [3] of the Index Performance Strategy Index Options.  This number will not decrease after the Issue Date.


3.]  Allocations must be made in whole percentages.







Variable Options:


Variable Account:  [Allianz Life of New York Variable Account C]







[AZL Money Market Fund


AZL MVP Balanced Index Strategy Fund


AZL MVP Growth Index Strategy Fund]







Index Options:


Index Account:  [Allianz Life of New York Separate Account IANY]


 


 Index Performance Strategy Index Options



	
Index

	
Buffer for all Index Years

	
Minimum Cap for all Index Years


	
[S&P 500®1 Index

	
[10.00]%

	
[1.50]%]


	
[Nasdaq-100®2 Index

	
[10.00]%

	
[1.50]%]


	
[Russell 2000®3 Index

	
[10.00]%

	
[1.50]%]

















 [1S&P® is a registered trademark of Standard & Poor’s Financial Services LLC (“S&P”) and Dow Jones® is a registered trademark of Dow Jones Trademark Holdings LLC (“Dow Jones”). These trademarks have 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 and Dow Jones®, Dow Jones Industrial AverageSM, DJIA and The Dow are trademarks of Dow Jones. These trademarks have been sublicensed for certain purposes by Allianz Life Insurance Company of New York (“Allianz Life of NY”). The S&P 500 and Dow Jones Industrial Average (DJIA) are products of S&P Dow Jones Indices LLC and/or its affiliates and have been licensed for use by Allianz. Allianz 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.]







[2The 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).]







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












S40876-NY