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  RILA292NY          Jackson National Life Insurance Company of New York®    Thank you for choosing Jackson National Life Insurance Company of New York, also referred to as "the  Company" or "Jackson of NY®."    READ YOUR CONTRACT CAREFULLY.    This annuity contract is issued by the Company and is a legal agreement between the Owner ("You") and  Jackson of NY.    PLEASE NOTE THAT THIS CONTRACT REFERS TO AND UTILIZES EXTERNAL INDEXES. WHILE  THE CONTRACT VALUES MAY BE AFFECTED BY THE EXTERNAL INDEXES, THE CONTRACT  DOES NOT DIRECTLY PARTICIPATE IN ANY STOCK OR EQUITY INVESTMENTS. AN INDEX  ADJUSTMENT TO THE INDEX ACCOUNT IS NOT GUARANTEED AND MAY VARY BASED UPON  THE PERFORMANCE OF THE INDEXES.    THE INDEX RETURN MAY BE POSITIVE, NEGATIVE OR ZERO AND INVESTMENT IN THIS  CONTRACT MAY RESULT IN A LOSS OF PRINCIPAL. IN SOME INSTANCES, THE POTENTIAL  INVESTMENT LOSS FOR THIS PRODUCT MAY BE SIGNIFICANTLY GREATER THAN THE  POTENTIAL INVESTMENT GAIN. IN EXCHANGE FOR SOME LOSS PROTECTION, YOU MAY  SACRIFICE POTENTIAL GAIN. THERE MAY BE LIMITS ON GAINS THAT COULD DELAY OR  PREVENT YOU FROM EARNING BACK LOSSES.    AMOUNTS ALLOCATED TO THE FIXED ACCOUNT WILL EARN INTEREST AT THE CURRENT  INTEREST RATE FOR THE DURATION OF THE FIXED ACCOUNT PERIOD. THE INTEREST RATE  CREDITED FOR SUBSEQUENT PERIODS IS SUBJECT TO CHANGE AS DECLARED BY THE  COMPANY.    THE WITHDRAWAL VALUE AVAILABLE UNDER THIS CONTRACT IS EQUAL TO THE CONTRACT  VALUE LESS ANY APPLICABLE WITHDRAWAL CHARGE.    PLEASE READ THE IMPORTANT CONTRACT DISCLOSURES ON THE FOLLOWING  PAGE.    NOTICE OF RIGHT TO EXAMINE CONTRACT  YOU MAY RETURN THIS CONTRACT TO THE FINANCIAL PROFESSIONAL WHO SOLD YOU THE  CONTRACT OR THE COMPANY WITHIN [10] DAYS AFTER YOU RECEIVE IT ([60] DAYS AFTER  YOU RECEIVE IT IF IT WAS PURCHASED AS A REPLACEMENT CONTRACT). THE COMPANY WILL  REFUND THE PREMIUM PAID TO THE FIXED ACCOUNT, LESS THE AMOUNT OF ANY PARTIAL  WITHDRAWALS FROM THE FIXED ACCOUNT, PLUS THE INDEX ACCOUNT VALUE WITHOUT  DEDUCTION FOR ANY FEES AND CHARGES. RETURNED CONTRACTS ARE VOID. INDIVIDUAL SINGLE PREMIUM DEFERRED  REGISTERED INDEX-LINKED ANNUITY.  DEATH BENEFIT AVAILABLE.  INCOME OPTION AVAILABLE.  NON-PARTICIPATING.  CONTAINS PROVISIONS WAIVING  WITHDRAWAL CHARGES.    Home Office: Customer Care Center:  [2900 Westchester Avenue [P.O. Box 24068  Purchase, New York 10577] Lansing, MI 48909-4068   1-800-599-5651  www.jackson.com]    This Contract is signed by the Company President    Secretary   

 

  RILA292NY Contract Cover Page Continued  Home Office:      Customer Care Center:     [2900 Westchester Avenue   [P.O. Box 24068  Purchase, New York 10577]  Lansing, MI 48909-4068  1-800-599-5651  www.jackson.com]       IMPORTANT - CONTRACT DISCLOSURES    PLEASE READ CAREFULLY          PLEASE REVIEW THE CONTRACT DATA PAGES FOR WITHDRAWAL CHARGE INFORMATION.    THE COMPANY MAY RESTRICT TRANSFERS TO INDEX ACCOUNT OPTIONS AT ANY  TIME, ON A NON-DISCRIMINATORY BASIS, IF THE YIELD ON INVESTMENT OR COST OF  HEDGING WOULD NOT SUPPORT THE MINIMUM GUARANTEES OF THE INDEX  ACCOUNT OPTION(S). HOWEVER, AT LEAST ONE (1) INDEX ACCOUNT OPTION WILL  ALWAYS REMAIN AVAILABLE FOR ALLOCATION. SHOULD THE COMPANY IMPOSE  SUCH RESTRICTIONS, THE COMPANY WILL GIVE AT LEAST 30 DAYS ADVANCE  NOTICE TO YOU. THE COMPANY WILL ALSO PROVIDE WRITTEN NOTICE WHEN SUCH  RESTRICTIONS NO LONGER EXIST.    THE COMPANY WILL NOT RESTRICT TRANSFERS TO THE FIXED ACCOUNT OPTION(S)  AT ANY TIME.        ffice: Customer Care Center: [  tchester Avenue [P.O. Box 24068  r ,  r  ] Lansing, MI 48909-4068   1-800-599-5651  www.jackson.com]  

 

  RILA292NY 2  TABLE OF CONTENTS     Provision Page Number    Contract Data Pages [3a    Definitions  4    General Provisions 8    Contract Option Provisions 13    Withdrawal Provisions 17    Death Benefit Provisions 23    Income Provisions 27    Termination Provisions 30]    If You have questions about this Contract or require information about coverage or complaint  resolutions, You may contact the Company's Customer Care Center identified on the Contract's  cover page.    

 

  RILA292NY-CB1 3a  CONTRACT DATA PAGES    Contract Number: [1234567890]     Owner: [John Doe]     Owner Issue Age: [81]     Joint Owner: [No Joint Owner]     Joint Owner Issue Age: [N/A]     Annuitant: [John Doe]     Annuitant Issue Age: [81]     Joint Annuitant: [No Joint Annuitant]     Joint Annuitant Issue Age: [N/A]     Issue Date: [June 1, 2023]     Issue State: NY     Premium Amount: [$25,000]     Income Date: [June 1, 2037]     Primary Beneficiary(ies): [Brian Doe]     Contingent Beneficiary(ies): [Jane Doe]                                  

 

  RILA292NY-CB1 3b  CONTRACT DATA PAGES (CONT'D)    FIXED ACCOUNT INFORMATION:    Initial 1-Year Fixed Account Option Interest Rate: [1.00%]    Fixed Account Minimum Interest Rate (FAMIR): [1.00%]    INTEREST RATE FOR ADJUSTMENTS DUE TO MISSTATEMENT OF AGE OR SEX: [1.00%]    WITHDRAWALS:    Withdrawal Charge Schedule:    Contract  Year  Withdrawal Charge  Percentage    1 8.00%  2 8.00%  3 7.00%  4 6.00%  5 5.00%  6 4.00%  7+ 0.00%         Please see Withdrawal Provisions for complete explanation of the determination of Withdrawal  Charges.     Minimum partial withdrawal amount unless as a scheduled part of an automatic  withdrawal program: [$500]    Minimum partial withdrawal amount as a scheduled part of an automatic withdrawal  program: [$50]    Minimum Contract Value remaining after a partial withdrawal: [$2,000]    Free Withdrawal Percentage: [10%]   

 

  RILA292NY-CB1 3c  CONTRACT DATA PAGES (CONT'D)    Waiver of Withdrawal Charge for Extended Care Eligibility Date: [June 1, 2024]    Waiver of Withdrawal Charge for Extended Care Maximum Amount: [100%] of the Contract  Value, not to exceed [$250,000]    PREMIUM:    This is a single Premium Contract. The Company may waive minimum and maximum Premium  at any time, on a non-discriminatory basis.     Minimum Premium: [$25,000]    Maximum Premium under a Contract: [$1,000,000]    SEPARATE ACCOUNT:    [JNLNY RILA Separate Account I]  

 

  RILA292NY-CB1 3d  CONTRACT DATA PAGES (CONT'D)    TABLE OF INCOME OPTIONS    The following table shows income values for each $1,000 of net proceeds applied to the Income  Option.    UNDER OPTION 4 MONTHLY INSTALLMENTS UNDER OPTIONS 1 OR 3      No. of  Monthly  Install- ments      Monthly  Install- ments      Age of  Annui- tant      No. of Mos.  Certain      Age of  Annui- tant      No. of Mos.  Certain      Age of  Annui- tant      No. of Mos.  Certain      Age of  Annui- tant      No. of Mos.  Certain  Male Life 120 240 Male Life 120 240 Female Life 120 240 Female Life 120 240  60 17.09 40 2.33 2.32 2.31 68 4.72 4.57 4.02 40 2.22 2.22 2.21 68 4.36 4.26 3.86  72 14.31 41 2.37 2.36 2.35 69 4.90 4.72 4.09 41 2.26 2.26 2.25 69 4.52 4.40 3.94  84 12.33 42 2.41 2.41 2.39 70 5.09 4.89 4.16 42 2.30 2.30 2.29 70 4.69 4.55 4.02  96 10.84 43 2.45 2.45 2.43 71 5.31 5.06 4.23 43 2.34 2.34 2.32 71 4.87 4.70 4.09  108 9.68 44 2.50 2.50 2.47 72 5.54 5.24 4.29 44 2.38 2.38 2.36 72 5.06 4.87 4.16  120 8.76 45 2.55 2.54 2.52 73 5.79 5.43 4.34 45 2.42 2.42 2.40 73 5.28 5.04 4.22  132 8.00 46 2.60 2.59 2.56 74 6.06 5.63 4.39 46 2.47 2.47 2.45 74 5.51 5.23 4.28  144 7.37 47 2.65 2.64 2.61 75 6.35 5.83 4.43 47 2.52 2.51 2.49 75 5.76 5.42 4.34  156 6.84 48 2.71 2.70 2.66 76 6.67 6.04 4.47 48 2.57 2.56 2.54 76 6.03 5.62 4.38  168 6.38 49 2.77 2.76 2.71 77 7.02 6.26 4.50 49 2.62 2.61 2.59 77 6.33 5.83 4.43  180 5.98 50 2.83 2.82 2.76 78 7.40 6.48 4.52 50 2.67 2.67 2.64 78 6.65 6.04 4.46  192 5.64 51 2.89 2.88 2.82 79 7.81 6.70 4.54 51 2.73 2.72 2.69 79 7.01 6.26 4.49  204 5.33 52 2.96 2.94 2.88 80 8.27 6.92 4.56 52 2.79 2.78 2.74 80 7.40 6.48 4.52  216 5.06 53 3.03 3.01 2.94 81 8.76 7.13 4.57 53 2.85 2.84 2.80 81 7.83 6.70 4.54  228 4.82 54 3.10 3.08 3.00 82 9.30 7.34 4.58 54 2.92 2.91 2.85 82 8.29 6.92 4.56  240 4.60 55 3.18 3.16 3.06 83 9.89 7.53 4.58 55 2.99 2.98 2.91 83 8.80 7.13 4.57  252 4.40 56 3.26 3.23 3.13 84 10.54 7.72 4.59 56 3.07 3.05 2.98 84 9.35 7.33 4.58  264 4.22 57 3.35 3.32 3.19 85 11.26 7.88 4.59 57 3.14 3.12 3.04 85 9.95 7.52 4.58  276 4.06 58 3.44 3.40 3.26 86 12.05 8.03 4.59 58 3.23 3.20 3.11 86 10.59 7.70 4.59  288 3.90 59 3.54 3.49 3.34 87 12.91 8.17 4.59 59 3.31 3.29 3.18 87 11.28 7.87 4.59  300 3.77 60 3.64 3.59 3.41 88 13.86 8.28 4.60 60 3.40 3.37 3.25 88 12.03 8.02 4.59  312 3.64 61 3.74 3.69 3.48 89 14.88 8.38 4.60 61 3.50 3.46 3.32 89 12.84 8.15 4.59  324 3.52 62 3.86 3.79 3.56 90 15.99 8.46 4.60 62 3.60 3.56 3.40 90 13.71 8.27 4.60  336 3.41 63 3.98 3.91 3.64 91 17.17 8.53 4.60 63 3.71 3.66 3.47 91 14.66 8.37 4.60  348 3.31 64 4.11 4.02 3.71 92 18.43 8.58 4.60 64 3.82 3.77 3.55 92 15.70 8.45 4.60  360 3.21 65 4.24 4.15 3.79 93 19.78 8.63 4.60 65 3.95 3.88 3.63 93 16.86 8.53 4.60    66 4.39 4.28 3.87 94 21.20 8.66 4.60 66 4.07 4.00 3.71 94 18.13 8.58 4.60    67 4.55 4.42 3.95 95 22.67 8.68 4.60 67 4.21 4.12 3.79 95 19.53 8.63 4.60    Note: Due to the volume of relevant information, the Table does not provide income values for  Option 2 described in the Income Provisions. Those values are available from the Company's  Customer Care Center upon request. You may contact the Company's Customer Care Center  as shown on the cover page of the Contract.    BASIS OF COMPUTATION. The 2012 Individual Annuity Mortality Period Table, with an  interest rate of 1.00% and a 0% expense load, provides the actuarial basis for the Table of  Income Options. The Table of Income Options does not include any applicable tax.  

 

  RILA292NY 4  DEFINITIONS    1-YEAR FIXED ACCOUNT OPTION. An account within the Fixed Account for allocation of  Premium or Contract Value. Premium or Contract Value can only be allocated on the Issue Date  or a subsequent Contract Anniversary.    ANNUITANT. The natural person(s) so designated on the Contract Data Pages, or by  subsequent designation, whose life determines the amount of Income Payments provided by  the Contract. References to the Annuitant include all Joint Annuitants, if applicable.    BENEFICIARY(IES). The natural person(s) or legal entity(ies) You designate as Primary or  Contingent Beneficiary(ies) to receive any death benefit provided by the Contract. The initial  Beneficiary(ies) are shown on the Contract Data Pages.    BUSINESS DAY. Any day that the New York Stock Exchange (NYSE) is open for business. The  Business Day ends when the NYSE closes for the day.    CONTRACT. The Individual Single Premium Deferred Registered Index-Linked Annuity  described herein.    CONTRACT ANNIVERSARY. The Business Day on or immediately following each one-year  anniversary of the Issue Date.    CONTRACT OPTION(S). The Contract Options for this Contract are the Fixed Account and the  Index Account.     CONTRACT VALUE. The Contract Value is equal to the sum of the Fixed Account Value and  the Index Account Value. See the Contract Option Provisions for details of how the Fixed  Account Value and Index Account Value are determined.     CONTRACT YEAR. The twelve-month period beginning on the Issue Date and on any Contract  Anniversary thereafter while the Contract remains in force.    CREDITING METHOD. A method of calculating the Index Adjustment. See the Crediting  Method Endorsements and Supplemental Contract Data Pages for details.    CUSTOMER CARE CENTER. The Company's administrative address and telephone number  as identified on the Contract's cover page or as the Company may designate from time to time.    DUE PROOF. Evidence of death includes a certified death certificate issued by the  governmental authority for the location of the death, or other lawful evidence the Company  requires.  

 

  RILA292NY 5  DEFINITIONS (CONT'D)    FIXED ACCOUNT. A Contract Option in which amounts earn a declared rate of interest for a  certain period.    FIXED ACCOUNT MINIMUM INTEREST RATE (FAMIR). The Fixed Account Minimum Interest  Rate is the minimum annual percentage at which Your money allocated to the Fixed Account  will grow. The Company uses this rate to determine the Fixed Account Minimum Value (FAMV).  The FAMIR is shown on the Contract Data Pages and is guaranteed for the life of the Contract.    FIXED ACCOUNT MINIMUM VALUE (FAMV). The FAMV is equal to all amounts allocated to  the Fixed Account, net of applicable taxes, reduced by partial withdrawals, transfers, and  charges from the Fixed Account, accumulated at the FAMIR, less any Withdrawal Charges or  tax due.    FIXED ACCOUNT OPTION. An option within the Fixed Account for allocation of Premium or  Contract Value. Each Fixed Account Option is defined by a term for which amounts earn a  declared rate of interest. The Fixed Account Options available are the 1-Year Fixed Account  Option and the Short Duration Fixed Account Option.    FIXED ACCOUNT VALUE. The Fixed Account Value is equal to:   1. the value of Premium and any amounts transferred into the Fixed Account; plus  2. interest credited daily at a rate not less than the FAMIR, as shown on the Contract Data  Pages, per annum; less  3. any gross partial withdrawals, including any Withdrawal Charges on such withdrawals; less  4. any amounts transferred out of the Fixed Account.   The Fixed Account Value will never be less than the FAMV.    GOOD ORDER. The Company's receipt of all Premium, information, documentation, and/or  instructions the Company requires before it will issue the Contract, credit any interest, or  execute any transaction.     INCOME DATE. The date on which Income Payments are scheduled to begin as described in  the Income Provisions. The Income Date must be at least thirteen (13) months after the  Contract Issue Date. The Income Date is shown on the Contract Data Pages.    INCOME OPTION. Payment options as provided under the Income Provisions.    INDEX(ES). A benchmark used to determine the Index Adjustment, if any, for a particular Index  Account Option. See the Supplemental Contract Data Pages for the available Indexes as of the  Issue Date.     INDEX ACCOUNT. A Contract Option in which amounts are subject to an Index Adjustment for  a specified period of time. See the Crediting Method Endorsements and Supplemental Contract  Data Pages for detailed descriptions of the Index Account Options within the Index Account.  Index Account Option availability is subject to change by the Company on a non-discriminatory  basis.    INDEX ACCOUNT OPTION. An option within the Index Account for allocation of Premium or  Contract Value. Each Index Account Option is defined by its term, Index, and Crediting Method.  

 

  RILA292NY 6  DEFINITIONS (CONT'D)    INDEX ACCOUNT OPTION TERM ANNIVERSARY. The Business Day concurrent with or  immediately following the end of an Index Account Option term.    INDEX ACCOUNT VALUE. The Contract Value allocated to the Index Account. The Index  Account Value is the sum of the Index Account Option values.    INDEX ADJUSTMENT. The adjustment amount to an Index Account Option on the Index  Account Option Term Anniversary. This adjustment can be positive or negative, depending on  Index performance and Crediting Method.    INDEX ADJUSTMENT FACTOR(S). Parameters used to determine the Index Adjustment.  These parameters are specific to the applicable Crediting Method(s). See the Crediting Method  endorsements and Supplemental Contract Data Pages for additional details.    INTERIM VALUE. The quantity used to adjust the Index Account Option value for withdrawals  or an Intra-Term Performance Lock prior to the end of the Index Account Option term. The  Interim Value uses prorated Index Adjustment Factor(s) based on the elapsed portion of the  Index Account Option term. For detailed information on the Interim Value, see the Crediting  Method endorsements and the Supplemental Contract Data Pages.    INTRA-TERM PERFORMANCE LOCK. An elective transaction that allows early transfer of the  Interim Value out of an Index Account Option to the Short Duration Fixed Account Option prior  to the Index Account Option Term Anniversary. Intra-Term Performance Lock may not be  available with all Crediting Methods. See the Crediting Method Endorsements for details.    INTRA-TERM PERFORMANCE LOCK DATE. The Business Day the Interim Value is  reallocated to the Short Duration Fixed Account Option in connection with an Intra-Term  Performance Lock.    ISSUE DATE. The date the Company issued the Contract. The Issue Date is shown on the  Contract Data Pages.    JOINT ANNUITANT. Each of multiple Annuitants.    JOINT OWNER. Each of multiple Owners.    LATEST INCOME DATE (LID). The Contract Anniversary on which You will be 95 years old, or  such date allowed by the Company on a non-discriminatory basis or required by a Qualified  Plan, law, or regulation.    NON-QUALIFIED CONTRACT. A contract that is issued apart from any Qualified Plan and  therefore is not subject to the requirements of Sections 401, 403, 408, or 408A of the Internal  Revenue Code, as amended.  

 

  RILA292NY 7  DEFINITIONS (CONT'D)    OWNER ("YOU," "YOUR"). The natural person(s) or legal entity(ies) that has all rights under  the Contract, and is shown on the Contract Data Pages, or by subsequent designation. In this  Contract, "You" and "Your" also mean the Owner. References to the Owner include the Joint  Owners, if applicable.    PREMIUM. Money paid into this Contract for allocation into the Contract Options.    QUALIFIED PLAN. A retirement plan which qualifies for favorable tax treatment under Sections  401, 403, 408, or 408A of the Internal Revenue Code, as amended.    REMAINING PREMIUM. Total Premium paid into the Contract reduced by withdrawals of  Premium before the withdrawal is adjusted for any charges, including Withdrawal Charges. This  value is used solely for the purpose of calculating the Withdrawal Charge.    REQUIRED MINIMUM DISTRIBUTION (RMD). For Qualified Plan contracts, the RMD is the  amount defined by the Internal Revenue Code and the implementing regulations as the  minimum distribution requirement that applies to this Contract.    SHORT DURATION FIXED ACCOUNT OPTION. A limited-purpose Fixed Account Option that  is used for Intra-Term Performance Locks. The Short Duration Fixed Account Option cannot be  independently elected.    WITHDRAWAL CHARGE. A charge assessed against certain withdrawals from the Fixed  Account Option(s) and/or the Index Account Option(s). The Withdrawal Charge Schedule is  shown on the Contract Data Pages.    WITHDRAWAL VALUE. The amount available upon a total withdrawal. The Withdrawal Value is  equal to the Contract Value, less any applicable Withdrawal Charge.  

 

  RILA292NY 8   GENERAL PROVISIONS    ANNUITANT. You may change the Annuitant at any time before the Income Date, unless the  Contract is owned by a legal entity. Unless You specify otherwise, a change of Annuitant will  take effect on the date the request is signed by You, subject to any payments the Company has  made or other actions the Company has taken before the Company receives Your request. The  Company reserves the right to limit the number of Joint Annuitants to two (2).     When the Owner is a legal entity, the Annuitant may not be changed. If the Contract is owned  by a legal entity, the Company will use the oldest Annuitant's age for all Contract purposes  unless otherwise specified in the Contract. When the Owner is a legal entity, the Annuitant(s)  shall be entitled to the benefits of the Waiver of Withdrawal Charge for Extended Care  provisions.     ASSIGNMENT. To the extent allowed by New York law, the Company may refuse consent to  any assignment at any time, on a non-discriminatory basis, if the assignment or ownership  change would result in noncompliance with any New York or federal regulation. Unless  restricted by endorsement, You may assign ownership of this Contract subject to the interests of  assignees and irrevocable Beneficiaries. The Company will only be bound by an assignment if a  request is submitted in a form acceptable to the Company and received in Good Order at the  Company's Customer Care Center. Unless You specify otherwise, an assignment will take effect  on the date the request is signed by You, subject to any payments the Company has made or  other actions the Company has taken before the Company receives Your request.     The Company assumes no responsibility for the validity or tax consequences of any  assignment. If You make an assignment, You may have to pay taxes. The Company  encourages You to seek legal and/or tax advice.    BENEFICIARY. You may change the Beneficiaries, subject to the interest of assignees and  irrevocable Beneficiaries. The Company will only be bound by a change in Beneficiary if a  request is submitted in a form acceptable to the Company, received in Good Order at the  Company's Customer Care Center. Any previously designated irrevocable Beneficiary must  consent in writing to any change in Beneficiary. Unless You specify otherwise, a change of  Beneficiary will take effect on the date the request is signed by You, subject to any payments  the Company has made or other actions the Company has taken before the Company receives  and records Your request, and while You are alive.    CONFORMITY WITH LAWS. This Contract will be interpreted under the law of the state of New  York as of the date it is issued and any applicable federal laws. Any provision that is in conflict  with New York law, or any federal law, is amended to conform to the minimum requirements of  such law. Non-conforming provisions may be enforced against the Company to the extent  provided by applicable New York or federal law.    DEFERRAL OF PAYMENTS. The Company may defer payment of Your request for a partial  and/or total withdrawal from the Contract for a period not exceeding six (6) months. Such  deferral will be made after the Company receives approval in writing by the chief insurance  regulator of the state of New York, if required. The Company will credit interest on deferred  amounts pursuant to New York law. The Company will not defer death benefit payments,  annuity payments, or payments made to comply with the RMD requirements of the Internal  Revenue Code, as applicable.  

 

  RILA292NY 9  GENERAL PROVISIONS (CONT'D)    ENTIRE CONTRACT. The Contract, attached application or supplemental application, if any,  and any attached endorsements, add-on benefits, and amendments together make up the entire  Contract between You and the Company. All statements made by, or under the authority of, the  applicant for issuance of the Contract shall be deemed representations and not warranties.     GENERAL ACCOUNT. The General Account is made up of all of Jackson's assets. The  Company exercises sole discretion over the investment of the General Account assets, and  bears the associated investment risk. You will not share in the investment experience of  General Account assets. All of the assets of the General Account are chargeable with the claims  of any of our contract owners as well as our creditors and are subject to the liabilities arising  from any of our other business.    INCONTESTABILITY. The Company will not contest this Contract from its Issue Date, as  shown on the Contract Data Pages.    MINIMUM VALUES. Any Withdrawal Values and death benefits that may be available under  this Contract are not less than the minimum benefits required by the state of New York.    MISSTATEMENT OF AGE AND/OR SEX. If Your or the Annuitant's age and/or sex is misstated  at the time the Contract's Income Payments become payable, the Company will adjust the  payments to reflect income consistent with the correct age and/or sex. Immediately upon  discovery, the Company will adjust the next payment due as a credit or charge, as appropriate,  for any underpayments or overpayments using the Interest Rate for Adjustments Due to  Misstatement of Age or Sex shown on the Contract Data Pages.    MODIFICATION OF CONTRACT. No financial professional has authority to change or waive  any of this Contract's provisions. No change to or waiver of this Contract's terms is valid unless  in writing and signed by the Company's President, Vice President, Secretary or Assistant  Secretary and approved by the New York Department of Financial Services prior to use. Your  written consent will be obtained prior to changing any terms and conditions of the Contract in a  manner that diminishes Your rights and/or benefits under the Contract.    NONPARTICIPATING. This Contract is nonparticipating and does not share in the Company's  surplus or earnings.  

 

  RILA292NY 10  GENERAL PROVISIONS (CONT'D)    OWNER. To the extent allowed by New York law, the Company may refuse consent to an  ownership change at any time, on a non-discriminatory basis, if the ownership change would  result in noncompliance with any New York or federal regulation. Unless restricted by  endorsement, or federal tax law, You may change the Owner or the Joint Owner. The Company  will use the oldest Owner's age for all Contract purposes unless otherwise specified in the  Contract. The Company will only be bound by a change of ownership if submitted in a form  acceptable to the Company and received in Good Order at the Company's Customer Care  Center. No person whose age exceeds the maximum issue age in effect for this Contract as of  the Issue Date may become a new Owner. Unless You specify otherwise, a change of  ownership will take effect on the date the request is signed by You, subject to any payments the  Company has made or other actions the Company has taken before the Company receives  Your request. Joint Owners have equal ownership rights; therefore, each Owner must authorize  any exercise of Contract rights unless the Joint Owners instruct the Company in writing to act  upon authorization of an individual Joint Owner. The maximum number of Joint Owners allowed  is two (2).     If the Owner is a natural person, then the Owner is the life the death benefit is based on. For  Contracts issued to Joint Owners, the death benefit is based on the first Joint Owner to die. If  the Owner is a legal entity, a Joint Owner is not permitted and the Annuitant is the life the death  benefit is based on. If the Owner is a legal entity and there are Joint Annuitants, the death  benefit is based on the first Joint Annuitant to die.    The Company assumes no responsibility for the validity or tax consequences of any  ownership change. If You make an ownership change, You may have to pay taxes. The  Company encourages You to seek legal and/or tax advice.    PROOF OF AGE, SEX AND/OR SURVIVAL. The Company may require proof of age and/or  sex, satisfactory to the Company, at any time. If any payment required by this Contract depends  on a living Annuitant, Owner, or Beneficiary, the Company may require proof of that person's  survival, satisfactory to the Company.    PROTECTION OF PROCEEDS. A Beneficiary may not assign Contract proceeds before the  proceeds are payable to such Beneficiary. Contract proceeds are not subject to the claims of  creditors or to legal process unless required by New York law.    

 

  RILA292NY 11  GENERAL PROVISIONS (CONT'D)    REPORTS. The Company will send a report to Your last address in the Company's records at  least annually before the Income Date. In the case of Joint Owners, the Company will send  reports only to the address of the first Owner listed on the Contract Data Pages. If You have  elected electronic delivery, a report may be provided in the form of an email to Your last email  address in the Company's records, or a notice to You of a document's availability on the  Company's website. Each report will provide at least the following information:  1. the dates that begin and end the reporting period;   2. the Contract Value at the beginning and at the end of the current reporting period;   3. the Withdrawal Value at the end of the reporting period;   4. the Withdrawal Charge the Company used to determine the Withdrawal Value;   5. the amounts the Company has credited to and deducted from the Contract Value during the  reporting period;  6. the death benefit at the end of the reporting period; and  7. any other information New York and federal law require.     You may receive copies of reports the Company provides upon request at no additional charge  by contacting the Company's Customer Care Center as shown on the cover page of the  Contract.    You will receive a confirmation statement for certain transactions at the time they occur.    SEPARATE ACCOUNT. The Company holds certain investments supporting the assets  allocated to the Index Account in a non-insulated, non-unitized Separate Account. The Separate  Account is established pursuant to the applicable law solely for the purpose of supporting  obligations under the Contract. You do not directly participate in the performance of assets held  in the Separate Account and do not have any direct claim on them. Assets of the Separate  Account are chargeable with the claims of any of the Company's contract owners as well as the  Company's creditors and are subject to the liabilities arising out of any other business the  Company conducts. The Separate Account is not registered under the Investment Company Act  of 1940. The name of the Separate Account is shown on the Contract Data Pages.     TAXES. This Contract is intended to be treated as an annuity contract for federal income tax  purposes. Accordingly, for all Non-Qualified Contracts all provisions of this Contract shall be  interpreted and administered in accordance with the requirements of Section 72(s) of the  Internal Revenue Code. The Company will deduct any taxes attributed to the Contract and  payable to the state of New York or other government entity from the Contract Value as they are  incurred. The Company reserves the right to deduct any amounts the Company might advance  to pay taxes from the Contract Value. The Company will withhold taxes required by law from  any amounts payable from this Contract. 

 

  RILA292NY 12  GENERAL PROVISIONS (CONT'D)    WRITTEN NOTICE. Written information or instructions You intend to give the Company must be  in Good Order and delivered to the Company's Customer Care Center in a format currently  accepted by the Company, unless the Company advises You otherwise. A notice relating to  Owner, Beneficiary designation or assignment changes shall take effect on the date the request  is signed by You, subject to any payments the Company has made or other actions the  Company has taken before the Company receives the request. Otherwise, instructions included  in a Written Notice will take effect on the date the Company receives the notice at the  Company's Customer Care Center.    The Company will deliver any notice or communication to Your last known address in the  Company's records unless You request otherwise in writing. If You have elected electronic  delivery, communication may be provided in the form of an email to Your last email address in  the Company's records, or a notice to You of a document's availability on the Company's  website. You are responsible for notifying the Company of any address change, email address  change, or any error in a Company notice sent to You. In the case of Joint Owners, the  Company will send notices and other communications to the address of the first Owner listed on  the Contract Data Pages.  

 

  RILA292NY 13  CONTRACT OPTION PROVISIONS    The Contract contains two (2) types of Contract Options: Fixed Account and Index Account.    Upon Good Order, all Premium will be allocated to the Contract Options as elected on the  application. No Premium will be accepted after the Issue Date.    FIXED ACCOUNT OPTIONS.    1-Year Fixed Account Option. The 1-Year Fixed Account Option is an annually renewable fixed  account. The Company will credit interest to amounts allocated to the 1-Year Fixed Account  Option. Such initial and renewal interest will be credited at such rate(s) as the Company  prospectively declares on a periodic basis, at the sole discretion of the Company for contracts  with the same Issue Date. On each Contract Anniversary the interest rate for the 1-Year Fixed  Account Option is subject to change. In no event will the interest rate credited by the Company to  the 1-Year Fixed Account Option be less than the FAMIR, as shown on the Contract Data Pages,  per annum.    Short Duration Fixed Account Option. The Short Duration Fixed Account Option is a limited  purpose Fixed Account Option used only for Intra-Term Performance Lock amounts. The interest  rate credited to amounts in the Short Duration Fixed Account Option is the rate currently declared  for the Short Duration Fixed Account Option. The interest rate is guaranteed until the next  Contract Anniversary. In no event will the interest rate credited by the Company to the Short  Duration Fixed Account Option be less than the FAMIR, as shown on the Contract Data Pages,  per annum.    On each Contract Anniversary, any Fixed Account Value in the Short Duration Fixed Account  Option will be automatically transferred out of the Short Duration Fixed Account Option. If no  other instructions are provided by the Owner, Short Duration Fixed Account Option value from an  Intra-Term Performance Lock, including interest, will be allocated to a new Index Account Option  with the same Index Account Option term, Index, Crediting Method, and negative Index  Adjustment protection as the Index Account Option the Intra-Term Performance Lock was  executed on, if it is available and does not extend beyond the LID.    Fixed Account Value. The Fixed Account Value is equal to (1) the value of Premium and any  amounts transferred into the Fixed Account Option(s); (2) plus interest credited daily at a rate not  less than the FAMIR, as shown on the Contract Data Pages, per annum; (3) less any gross  partial withdrawals, including any Withdrawal Charges on such withdrawals; (4) less any amounts  transferred out of the Fixed Account Option(s). The Fixed Account Value will never be less than  the FAMV.    INDEX ACCOUNT OPTIONS. An option within the Index Account for allocation of Contract  Value, defined by term, Index, and Crediting Method. The terms, Indexes, and Crediting Methods  available as of the Issue Date are shown on the Supplemental Contract Data Pages. Availability  of terms, Indexes, and Crediting Methods are subject to change at the sole discretion of the  Company on a non-discriminatory basis. 

 

  RILA292NY 14  CONTRACT OPTION PROVISIONS (CONT'D)    Index Account Value. The Index Account Value is equal to the sum of the Index Account Option  values.    The Index Account Option value at the beginning of the Index Account Option term is equal to the  amount allocated or transferred to the Index Account Option less the amount transferred out of  the Index Account Option.    During the Index Account Option term, the Index Account Option value is equal to the Interim  Value. The Interim Value is the greater of the Index Account Option value at the beginning of the  term reduced for any Intra-Term Performance Locks and withdrawals from the Index Account  Option during the Index Account Option term, including any Withdrawal Charges, in the same  proportion as the Interim Value was reduced on the date of the Intra-Term Performance Lock or  withdrawal, plus the Index Adjustment subject to prorated Index Adjustment Factor(s), or zero.  Additional detail on Index Adjustment Factor(s) can be found in the Crediting Method  endorsements and Supplemental Contract Data Pages.    On the Index Account Option Term Anniversary, the Index Account Option value is equal to the  greater of the Index Account Option value at the beginning of the Index Account Option term,  reduced for any Intra-Term Performance Lock and withdrawals from the Index Account Option  during the Index Account Option term, including any Withdrawal Charges, in the same proportion  as the Interim Value was reduced on the date of the Intra-Term Performance Lock or withdrawal,  plus the Index Adjustment subject to Index Adjustment Factor(s), or zero. Additional detail on  Index Adjustment Factor(s) can be found in the Crediting Method endorsements and  Supplemental Contract Data Pages.    TRANSFERS. Transfers may only occur on the Contract Anniversary, when transferring out of  the Fixed Account Option(s), and on the Index Account Option Term Anniversary when  transferring out of an Index Account Option. You will be sent a notice thirty (30) days prior to the  Contract Anniversary and/or Index Account Option Term Anniversary. The notice will advise You  of how You may obtain information on the Contract Options and current rates available to You.  You may request a transfer to or from the 1-Year Fixed Account Option and to or from the Index  Account Option(s). You may also request transfers among the available Index Account Options  within the Index Account. A request for a transfer must be received in Good Order at the  Company's Customer Care Center prior to the Contract Anniversary or Index Account Option  Term Anniversary, as applicable.     If no transfer request is received on or prior to the Contract Anniversary, the 1-Year Fixed  Account Option value will remain in the 1-Year Fixed Account Option.    

 

  RILA292NY 15  CONTRACT OPTION PROVISIONS (CONT'D)    If no transfer request is received on or prior to the Index Account Option Term Anniversary, the  Index Account Option value(s) will be reallocated as follows:  1. if the same Index Account Option term with the same Index, Crediting Method, and negative  Index Adjustment protection is available at the time and does not extend beyond the LID,  the Company will renew the Index Account Option into the same Index Account Option term  with the same Index, Crediting Method, and downside protection;  2. if the same Index Account Option term with the same Index, Crediting Method, and negative  Index Adjustment protection is available at the time but extends beyond the LID, the  Company will select the available Index Account Option term with the same Index, Crediting  Method, and downside protection that ends closest to but before the LID;  3. if the same Index Account Option term is not available at the time but would not extend  beyond the LID were it available, the Company will select the available Index Account  Option term with the period closest to but less than the Index Account Option term that just  ended with the same Index and Crediting Method as well as the closest equal or greater  downside protection available for that term.    If the Crediting Method or Index is no longer available as of the Index Account Option Term  Anniversary, the Index Account Option value(s) will be reallocated to the 1-Year Fixed Account  Option.    Transfers into the Short Duration Fixed Account Option are only allowed in connection with an  Intra-Term Performance Lock.    Transfers from an Index Account Option in connection with an Intra-Term Performance Lock  may occur at any time, see Intra-Term Performance Lock for details.    Unless specified otherwise, transfers on a Contract Anniversary will be taken from the Index  Account Option(s) that have reached their Index Account Option Term Anniversary and the  Fixed Account Option(s) in proportion to their current value. The Company reserves the right to  restrict or prohibit transfers from the 1-Year Fixed Account Option to the Index Account Option  on a non-discriminatory basis, at any time.    Transfers from a Fixed Account Option will reduce the Fixed Account Value by the transfer  amount requested. Transfers into a 1-Year Fixed Account Option will increase the 1-Year Fixed  Account Option value by the transfer amount requested. Transfers from an Index Account  Option will reduce the Index Account Option value by the transfer amount requested. Transfers  into an Index Account Option will increase the Index Account Option value by the transfer  amount requested.    The Company may restrict transfers to an Index Account Option(s) at any time, on a non- discriminatory basis, if the yield on investment or cost of hedging would not support the  minimum guarantees of the Index Account Option(s). However, at least one (1) Index Account  Option will always remain available for allocation. Should the Company impose such  restrictions, the Company will give at least thirty (30) days advance notice to You. The Company  will also provide Written Notice when such restrictions no longer exist.    Whenever the Company restricts or discontinues an Index Account Option(s), the Company will  waive all Withdrawal Charges while those restrictions/discontinuations are in effect.  

 

  RILA292NY 16  CONTRACT OPTION PROVISIONS (CONT'D)    Intra-Term Performance Lock. Prior to the Index Account Option Term Anniversary, You may  elect to transfer the Interim Value of an Index Account Option into the Short Duration Fixed  Account Option by requesting an Intra-Term Performance Lock subject to the following:  1. To execute an Intra-Term Performance Lock, the Owner must specify the Crediting Method,  Index, Index Account Option term, and Index Adjustment Factor(s) of the Index Account  Option(s) from which to execute the Intra-Term Performance Lock. Intra-Term Performance  Lock may not be available with all Crediting Methods. See the Crediting Method  Endorsements for details;  2. All Interim Value with the specified combination of Crediting Method, Index, Index Account  Option term, and Index Adjustment Factor(s) will be subject to the Intra-Term Performance  Lock. Partial Intra-Term Performance Locks for a given Crediting Method, Index, Index  Account Option term, and Index Adjustment Factor(s) will not be allowed.    The Interim Value transferred to the Short Duration Fixed Account Option will be equal to the  Interim Value at the end of the Business Day the request is received in Good Order at the  Company's Customer Care Center. The entire Interim Value of the Index Account Option  subject to the Intra-Term Performance Lock will be transferred to the Short Duration Fixed  Account Option on the Intra-Term Performance Lock Date and will receive the current interest  rate declared for amounts in the Short Duration Fixed Account Option as of the Intra-Term  Performance Lock Date. This interest rate will be guaranteed until the next Contract  Anniversary.    The amounts subject to the Intra-Term Performance Lock will remain in the Short Duration  Fixed Account Option until the next Contract Anniversary, at which time the Owner can  reallocate to any available Contract Option. If no other instructions are provided by the Owner,  the Short Duration Fixed Account Option value from an Intra-Term Performance Lock, including  interest, will be allocated to a new Index Account Option with the same Index Account Option  term, Index, Crediting Method, and negative Index Adjustment protection as the Index Account  Option the Intra-Term Performance Lock was executed on, if it is available and does not extend  beyond the LID.    Periodic Reallocation Programs. The Company may provide programs that allow You to  systematically transfer amounts between the Contract Options. These programs may include  rebalancing and the automatic transfer of positive Index Adjustments from the Index Account  Options to the 1-Year Fixed Account Option. You may contact the Company's Customer Care  Center to obtain materials and forms that describe, and are required to participate in, these  programs. The Company makes no guarantee that these programs will result in a profit or  protect against loss.  

 

  RILA292NY 17  WITHDRAWAL PROVISIONS    On or before the Income Date, You may request a total or partial withdrawal of the Contract  Value by submitting a request to the Company's Customer Care Center in a form acceptable to  the Company.    The withdrawal will be processed after a withdrawal request is received at the Company's  Customer Care Center in Good Order. If a total withdrawal is requested, You must submit the  Contract to the Company's Customer Care Center with the withdrawal request.    No withdrawal may exceed the Withdrawal Value.    TOTAL WITHDRAWAL. The Withdrawal Value for a total withdrawal from the Contract is equal  to the Contract Value less any Withdrawal Charge. A total withdrawal terminates Your Contract.    In no event will a total withdrawal from the Fixed Account be less than the FAMV.    PARTIAL WITHDRAWAL. Any partial withdrawal may be subject to a Withdrawal Charge. At  least the Minimum Contract Value remaining after a partial withdrawal, as shown on the  Contract Data Pages, must remain after any partial withdrawal. Unless You request otherwise, a  gross partial withdrawal will be deducted from the Fixed Account Option(s) and the Index  Account Option(s) in proportion to their current values. The gross partial withdrawal will be  reduced for any applicable Withdrawal Charge.     If the gross amount of the partial withdrawal would reduce the Contract Value below the  Minimum Contract Value remaining after a partial withdrawal, as shown on the Contract Data  Pages, the Company will treat the withdrawal request as a total withdrawal and the Withdrawal  Value will be paid.    The amount payable as a result of the partial withdrawal will be determined at the end of the  Business Day on which the Company receives Your request for withdrawal in Good Order at the  Company's Customer Care Center.     Partial Withdrawals will reduce each Index Account Option's value at the beginning of the term  in the same proportion that its Interim Value was reduced on the date of the withdrawal.     Any overpayments made by the Company to You in error must be returned within thirty (30)  days from the date You are notified of the overpayment, or the Company will reduce Your  Contract Value for the amount of the overpayment. If the overpayment exceeds the Contract  Value, You are responsible for returning the remaining portion of the overpayment to the  Company.    QUALIFIED PLAN CONTRACT REQUIRED MINIMUM DISTRIBUTIONS. Qualified Plan  Contract RMDs are based upon Your Contract Value, and applicable federal tax law  requirements. You may request a withdrawal for an RMD by submitting a written request to the  Customer Care Center on a Company provided form.  

 

  RILA292NY 18  WITHDRAWAL PROVISIONS (CONT'D)    The Company will waive any Withdrawal Charge if the gross amount withdrawn does not  exceed the Contract's RMD amount, as determined by the Company. However, if a gross  withdrawal amount is greater than the Contract's RMD amount, as determined by the Company,  the excess amount of the gross partial withdrawal is subject to a Withdrawal Charge.    AUTOMATIC WITHDRAWAL. You may elect to take an automatic withdrawal by withdrawing a  specific sum or a certain percentage of the Contract Value on a monthly, quarterly, semiannual,  or annual basis, subject to the Minimum Partial Withdrawal amount made as a scheduled part of  an automatic withdrawal program, as shown on the Contract Data Pages. Automatic  withdrawals are treated as partial withdrawals and will be counted in determining the amount  taken as a Free Withdrawal in any Contract Year. Automatic withdrawals in excess of the Free  Withdrawal amount may be subject to Withdrawal Charges. Automatic withdrawals cease on the  Income Date.    WITHDRAWAL CHARGE. The Company may impose a Withdrawal Charge against certain  withdrawals from the Contract. The Company will calculate Withdrawal Charges in accordance  with the Withdrawal Charge Schedule shown on the Contract Data Pages.    For purposes of determining the Withdrawal Charge, the Contract Value is divided into earnings  and Remaining Premium, as defined in the Contract. Earnings are not subject to a Withdrawal  Charge. For the sole purpose of determining the amount of the Withdrawal Charge, earnings  are defined as any excess of the Contract Value over Remaining Premium.     The Withdrawal Charge is equal to the applicable Withdrawal Charge Percentage applied to the  gross amount of Remaining Premium withdrawn (not the net amount of Remaining Premium  received by You), excluding any amount for which the Contract expressly provides for a waived,  or no, Withdrawal Charge. In the event of a total withdrawal, the applicable Withdrawal Charge  Percentage is applied to the full value of Remaining Premium immediately prior to the  withdrawal, less any Free Withdrawal available at the time of the total withdrawal. The  Withdrawal Charge reduces Remaining Premium and Contract Value. The Withdrawal Charge  will be taken from the Contract Options in the same proportion as the requested withdrawal.    Withdrawals will be allocated first to earnings (which may be withdrawn free of any Withdrawal  Charge), if any, and second to Remaining Premium.    

 

  RILA292NY 19  WITHDRAWAL PROVISIONS (CONT'D)    FREE WITHDRAWAL. During each Contract Year, You may make partial withdrawals from the  Contract without incurring a Withdrawal Charge. The amount of Free Withdrawal available in  any Contract Year is equal to the greater of:  1. any applicable RMD less earnings; or  2. the total of:  a. the Free Withdrawal Percentage, as shown on the Contract Data Pages, multiplied by  the Remaining Premium at the beginning of the Contract Year that is subject to a  Withdrawal Charge according to the Withdrawal Charge Schedule shown on the  Contract Data Pages; less  b. earnings; or  3. zero.    Earnings is defined in the Withdrawal Charge provision of this Contract.    The Free Withdrawal can be taken as a single withdrawal or multiple withdrawals throughout the  Contract Year. The amount of Your Free Withdrawal available will vary throughout the Contract  Year depending on previous withdrawals of Your Free Withdrawal amount, previous withdrawals  of earnings, and the amount of earnings present at the time of the withdrawal. The amount of  Your Free Withdrawal available may reduce due to withdrawals during the Contract Year.    Any amount withdrawn to satisfy an RMD may reduce the amount of Your Free Withdrawal  available.    Free Withdrawals are subject to the provisions of Partial Withdrawals and Total Withdrawals.     Amounts withdrawn under the Free Withdrawal provision reduce the Contract Value and may  reduce Remaining Premium.     Withdrawals during the Contract Year in excess of the Free Withdrawal may be subject to any  applicable Withdrawal Charges.    

 

  RILA292NY 20  WITHDRAWAL PROVISIONS (CONT'D)    WAIVER OF WITHDRAWAL CHARGE FOR EXTENDED CARE.    If You are confined as an inpatient in a Nursing Home or Hospital for ninety (90) consecutive  days starting after the Issue Date shown on the Contract Data Pages, the Company will waive  the Withdrawal Charge on the amount You withdraw from the Contract up to the Waiver of  Withdrawal Charge for Extended Care maximum amount shown on the Contract Data Pages.  Upon Your compliance with the Claim Requirements described below, You will be eligible for  this waiver on the Eligibility Date shown on the Contract Data Pages. All other Contract values  will be reduced proportionately for the amount withdrawn.    The Company will allocate the withdrawal amount to each Contract Option according to the  method described in the Withdrawal Provisions. The Company will determine values at the end  of the Business Day on which the Company receives the request for withdrawal in Good Order  at the Company's Customer Care Center. Withdrawals under this provision may reduce  Remaining Premium.    The availability of access to guarantees or values is not intended to provide long-term care or  nursing home insurance.    This Waiver of Withdrawal Charge for Extended Care is available only once, no matter the  amount withdrawn or in the circumstances of multiple confinements for the same or a different  medical condition and/or Joint Owners.     For the purpose of this waiver, the following definitions apply:     Hospital. A facility that:  1. is located within the United States or its territories;  2. operates primarily for the inpatient care and treatment of sick and injured persons;  3. provides continuous twenty-four (24) hour a day nursing service by or under the  supervision of a registered nurse (R.N.);  4. is supervised by a staff of licensed physicians; and  5. has its own medical and diagnostic facilities or has access to such facilities on a  prearranged basis.     Immediate Family - means the individual's spouse, domestic partner, child, brother, sister,  parent, or grandparent.     Medically Necessary - means consistent with Your diagnosis in accordance with accepted  standards of medical practice without which Your medical condition would be adversely  affected. 

 

  RILA292NY 21  WITHDRAWAL PROVISIONS (CONT'D)     Nursing Home. A facility that:  1. is licensed by the appropriate governmental licensing agency as a Nursing Home in the  state in which it maintains such facilities;  2. issues patients, or their insurance provider, a bill or amount due;  3. is primarily engaged in providing nursing care (skilled, intermediate or custodial) by or  under the supervision of a licensed Physician and room and board accommodations;  4. provides continuous twenty-four (24) hour a day nursing services by or under the  supervision of a registered nurse (R.N.);  5. maintains a daily medical record of each patient; and  6. maintains control and records of dispensed medications.     Physician - means an individual who is licensed to practice medicine and treat illness or  injury in the state where treatment is received and who is acting within the scope of his or  her license. The term Physician only refers to a Physician licensed and currently practicing  in the United States or its territories. The term Physician does not include:  1. an Annuitant or Joint Annuitant;  2. an Owner or Joint Owner;  3. a Beneficiary;  4. a member of the Annuitant's, Joint Annuitant's, Owner's or Joint Owner's Immediate  Family.     Physician's Statement - means a written statement signed by a Physician which provides  the Physician's diagnosis of Your medical condition.    You will be considered confined to a Nursing Home or Hospital only if Your confinement is  prescribed by a Physician and Medically Necessary. 

 

  RILA292NY 22  WITHDRAWAL PROVISIONS (CONT'D)    Claim Requirements. Ninety (90) days after the date of Your confinement, You may submit a  request, which must include (1) a completed claim form, (2) Your signed release for records of  all Physicians and institutions that have treated You for the medical condition You claim, and (3)  a Physician's Statement to the Company's Customer Care Center in Good Order.     The Company will send You a form to claim the Waiver of Withdrawal Charge for Extended  Care within ten (10) Business Days of the Company's receipt of Your request. If the Company  fails to send the claim form within ten (10) Business Days, You will be deemed to have complied  with the above claim requirements.    Claim Determination. Upon receipt of the Claim Requirements, the Company will complete an  initial review for Good Order within thirty (30) Business Days. The Company reserves the right  to deny Your claim if You do not satisfy the Claim Requirements. If the Company denies Your  Waiver of Withdrawal Charge for Extended Care claim, the Company will send You a letter with  the reason(s) for the denial. If You would like to appeal the Company's denial of Your Waiver of  Withdrawal Charge for Extended Care claim, You may submit a Written Notice to the  Company's Customer Care Center. If You are unable to satisfy the Claim Requirements, You  will then have the opportunity to submit a standard withdrawal request, subject to any applicable  Withdrawal Charge. Termination of the Contract will not prejudice any payment made under the  extended care waiver that occurred while this Contract was in force.    YOU MAY OWE TAX ON WITHDRAWALS FOR EXTENDED CARE. THE COMPANY  ENCOURAGES YOU TO SEEK LEGAL AND/OR TAX ADVICE.  

 

  RILA292NY 23  DEATH BENEFIT PROVISIONS    NATURAL OWNER'S DEATH BEFORE THE INCOME DATE. Upon Your death or the death of  any Joint Owner before the Income Date, the Company will pay the death benefit to the  Beneficiary(ies) designated by You, subject to the following:  1. On jointly owned Contracts, upon the death of the first Joint Owner, the surviving Joint  Owner becomes the Primary Beneficiary. If the surviving Joint Owner dies prior to the  Income Date and prior to submitting a claim form in Good Order, any remaining death  benefit will be paid to the Beneficiary(ies) in accordance with the last Beneficiary designation  received by the Company in Good Order before the last Joint Owner's death;  2. On all Contracts, if no Beneficiary designation is in effect, or the designated Beneficiary(ies)  have not survived the Owner, or both Joint Owners in the case of a jointly owned Contract,  the death benefit shall be paid to the Owner's estate, or the estate of the last Joint Owner to  die in the case of a jointly owned Contract.    ANNUITANT'S DEATH BEFORE THE INCOME DATE. Upon the death of an Annuitant who is  not an Owner before the Income Date, the Contract remains in force and the Owner becomes  the Annuitant. The Owner may designate a new Annuitant, subject to the Company's  administrative rules then in effect. No death benefit is payable on the death of an Annuitant who  is not also an Owner.     However, if the Contract is owned by a legal entity, the death of the Annuitant (in the case of  Joint Annuitants, the death of the first Annuitant) is treated as the death of the Owner for  purposes of these Death Benefit Provisions, and the Company will pay the death benefit to the  Beneficiary(ies) designated by the Owner, or, if no Beneficiary(ies) survive the applicable death,  to the Owner.    DEATH BENEFIT AMOUNT BEFORE THE INCOME DATE. The death benefit amount before  the Income Date is equal to the current Contract Value.    

 

  RILA292NY 24  DEATH BENEFIT PROVISIONS (CONT'D)    DEATH BENEFIT PAYMENT OPTIONS BEFORE THE INCOME DATE. Unless You  designated a Pre-selected Death Benefit Option, a Beneficiary entitled to the death benefit  before the Income Date must request that the Company pay the death benefit according to one  of the death benefit options below, or, if eligible, to continue the Contract under the Spousal  Continuation Option Instead of Death Benefit provision:    Option 1 - single lump-sum payment, paid immediately upon the Company's receipt of Due   Proof of the relevant death and a claim form in Good Order;  Option 2 - payment of the entire death benefit distributed within five (5) years of the date of the   relevant death; or  Option 3 - Income Payments of the death benefit with distributions beginning within one (1) year   of the date of the relevant death:  (i) over the lifetime of the Beneficiary; or  (ii) over a period not extending beyond the life expectancy of the Beneficiary.    The Company may make available other death benefit payment options.    A Beneficiary that wishes to elect payment under Option 3 must do so no later than sixty (60)  days from the date the Company receives Due Proof of death in Good Order at the Company's  Customer Care Center.    Any portion of the death benefit not applied under Option 3 must be paid within five (5) years  from the relevant death. The death benefit will remain invested in accordance with the allocation  selected by You until a Death Benefit Option is selected or the Beneficiary specifies otherwise.    DEATH BENEFIT PAYMENT OPTIONS FOR QUALIFIED PLANS. For Qualified Plans, the  death benefit payment options may be limited under the terms of the plan endorsement in order  to qualify under the Internal Revenue Code.     BENEFICIARY'S ENTITLEMENT TO DEATH BENEFIT BEFORE THE INCOME DATE. The  Company will pay the death benefit to Primary Beneficiaries or, if none exist, to Contingent  Beneficiaries, in equal shares (the "default allocation") unless You have designated otherwise  (the "designated allocation"). A Beneficiary that dies before or within ten (10) days (or different  period as prescribed by New York law) of Your death is not entitled to any death benefit. In that  circumstance, the Company will pay the deceased Beneficiary's share of the death benefit to  surviving Beneficiaries in the same proportion as the designated allocation or, if applicable, the  default allocation. A Contingent Beneficiary has no rights unless the Contingent Beneficiary  survives all Primary Beneficiaries who would have been entitled to receive payments under the  Contract had they survived. If no Beneficiary survives You, the Company will pay the death  benefit to Your estate. 

 

  RILA292NY 25  DEATH BENEFIT PROVISIONS (CONT'D)    PAYMENT OF DEATH BENEFIT. The death benefit will be determined at the time the  Company has received the first Due Proof of the relevant death and a claim form in Good Order  from a Beneficiary. The Company will pay the death benefit to the Beneficiary upon receipt of a  request for payment with Due Proof of the relevant death in Good Order at the Company's  Customer Care Center. If the Company has received Due Proof of death, the Company will  calculate the share of the death benefit due to a Beneficiary using Contract values established  at the end of the Business Day on the date the Company receives a claim form with a payment  option elected from that Beneficiary. If the Company has not received Due Proof of death or any  other required documentation, the Company will calculate the share of the death benefit due to  a Beneficiary using Contract values established at the end of the Business Day on the date the  Company receives any remaining required documentation. Index Adjustments may cause the  calculation of a Beneficiary's death benefit share to differ from the calculation of another  Beneficiary's death benefit share.     Each Beneficiary entitled to the death benefit bears the investment risk associated with amounts  allocated to any Index Account Option until the Company receives that Beneficiary's claim form  in Good Order at the Company's Customer Care Center and calculates their share of the death  benefit.    If any death benefit is due to an Owner's estate, the Company will pay the benefit in a single  lump-sum payment.     Payment to a Beneficiary in a single lump-sum will include interest on the death benefit at a rate  required by New York state law, from the date the Company receives the Due Proof of death  and a claim form in Good Order until the date the death benefit is paid.    The Company will pay the death benefit, including any interest, in accordance with New York  laws and regulations governing death benefit payments and in accordance with the Company's  administrative procedures. 

 

  RILA292NY 26  DEATH BENEFIT PROVISIONS (CONT'D)    Spousal Continuation Option Instead of Death Benefit. Unless the Contract is subject to a  Pre-selected Death Benefit Option, a Joint Owner or sole Beneficiary who is the surviving  spouse of the deceased Owner has the option to continue the Contract in his or her own name  as described below and exercise the Owner's rights under the Contract instead of taking the  standard death benefit.    The Spousal Continuation Option may be elected only if the Company receives the surviving  spouse's claim form electing the option and Due Proof of the relevant death in Good Order, at  the Company's Customer Care Center while the surviving spouse is alive. The "continuation  date" is the date on which the Company receives such claim form and Due Proof of death.    The Spousal Continuation Option is not available on or after the Income Date, nor where the  original Contract Owner is no longer the Contract Owner, the Contract has been assigned, or  You designated a Pre-selected Death Benefit Option. The Spousal Continuation Option may be  elected only once.    Pre-selected Death Benefit Option. Before the Income Date, You may designate the option  according to which the Company will pay the death benefit from the death benefit payment  options described in the Contract, or other death benefit options made available by the  Company. You may do so by submitting a designation in a form acceptable to the Company in  Good Order to the Company's Customer Care Center. Pre-selected Death Benefit Options will  take effect on the date the request is signed by You, subject to any payments the Company has  made or other actions the Company has taken before the Company received Your request. The  Company will pay the death benefit consistent with Your Pre-selected Death Benefit Option  unless the Internal Revenue Code requires otherwise, or Your election requires payment over a  period that exceeds the Beneficiary's life expectancy.    Only You may revoke or change a Pre-selected Death Benefit Option. To do so, You must  submit a request in a form acceptable to the Company to the Company's Customer Care  Center. Unless You specify otherwise, revocations of and changes to a Pre-selected Death  Benefit Option will take effect on the date the request is signed by You, subject to any payments  the Company has made or other actions the Company has taken before the Company received  Your request.  

 

  RILA292NY 27  INCOME PROVISIONS    INCOME DATE. Income Payments begin on the Income Date. The Income Date must be at  least thirteen (13) months after the Contract Issue Date. If You do not select an Income Date,  the Income Date is the LID. You may change the Income Date by submitting Written Notice in  Good Order to the Company's Customer Care Center at least seven (7) days before the current  Income Date. The LID may be changed to a later date upon request, if the Company agrees to  the change in writing. Requests to extend the LID must be submitted in writing and received by  the Company's Customer Care Center at least seven (7) days before the current LID.    INCOME PAYMENT. On or before the Income Date, You may elect payment in a single lump- sum. A single lump-sum payment is considered a total withdrawal and terminates the Contract.  The Company will make payment to You or another payee You specify. Alternatively, You may  elect an Income Option to begin on the Income Date. The Company will apply the Contract  Value, less applicable taxes, to provide You income according to Your selected Income Option.     INCOME OPTIONS. You may elect payment as provided in Options 1, 2, 3, or 4 below. You  may elect an Income Option up to thirty (30) days before the Income Date by submitting Written  Notice in Good Order to the Company's Customer Care Center. The Company will make  payment to You or another payee You specify.    If You do not select an Income Option the Company will make payments as provided in Option 3  below, with 120 months certain. The Company will make payments monthly, quarterly,  semiannually, or annually as You elect. However, if the Contract Value on the Income Date is  less than $2,000, the Company may pay out the Contract Value in one (1) lump-sum payment  instead of providing Income Payments according to the Income Option You elect. The single  lump-sum payment will not be less than the amount which would have been applied under an  Income Option on the Income Date. If the first monthly payment provided would be less than  $20, the Company may make payments quarterly, semiannually, or annually to achieve an initial  payment of at least $20, or the Company may pay out the Contract Value in one (1) single lump- sum payment.    At the time of their commencement, Income Payments will not be less than those that would be  provided by the application of an equivalent amount to purchase a single premium immediate  annuity contract from the Company at purchase rates the Company offered on the Income Date  to annuitants in the same class as the Annuitant.    The amount applied to an Income Option will not be less than the greater of the Withdrawal  Value or 95% of the Contract Value.    YOU MAY NOT TAKE WITHDRAWALS DURING ANY PERIOD THE COMPANY IS MAKING  PAYMENTS FOR AN ANNUITANT'S LIFETIME.    OPTION 1 - LIFE INCOME. A monthly payment for the Annuitant's lifetime. All payments end  upon the Annuitant's death. However, in the event of the Annuitant's death before the first  monthly payment, the Company will pay the amount allocated to this Income Option to You or, if  You are deceased, to Your Beneficiary.  

 

  RILA292NY 28  INCOME PROVISIONS (CONT'D)    OPTION 2 - JOINT AND SURVIVOR INCOME. A monthly payment for the longer of the  Annuitant's lifetime or that of a Joint Annuitant. Upon the occasion of the first person to die,  monthly payments continue during the survivor's lifetime at either the full amount previously  payable or as a percentage (either one-half or two-thirds) of the full amount, as You select at the  time You elect the Income Option.    All payments end upon the death of the last surviving Annuitant. However, in the event of the  deaths of the Annuitant and Joint Annuitant before the first monthly payment, the Company will  pay the amount allocated to this Income Option to You or, if You are deceased, Your  Beneficiary.    OPTION 3 - LIFE INCOME WITH 120 OR 240 MONTHLY PAYMENTS GUARANTEED.  A monthly payment for the Annuitant's lifetime with the guarantee that the Company will make at  least 120 or 240 monthly payments, whichever You elect, to You. If the Owner is an entity, at  the Annuitant's death, if fewer than the guaranteed number of payments have been made, the  remaining guaranteed payments will be made to the Owner as previously scheduled. If the  Owner is the Annuitant, in the event You die before the Company makes the specified number  of guaranteed payments, the Income Payments will be made to Your Beneficiary according to  the terms of this Contract unless the Beneficiary elects to receive the present value of any  remaining guaranteed payments in a single lump-sum payment. The present value of any  remaining guaranteed payments will be based on the total Income Payments as of the date of  the calculation. The Company will determine the interest rate used in this present value  calculation, but in no instance will it be greater than one (1) percentage point higher than the  rate used to calculate the initial Income Payment.    OPTION 4 - INCOME FOR A SPECIFIED PERIOD. A monthly payment for any whole number  of years ranging from 5 to 30. In the event You die before the Company makes the specified  number of payments, the Income Payments will be made to Your Beneficiary according to the  terms of this Contract unless the Beneficiary elects to receive the present value of any  remaining guaranteed payments in a single lump-sum payment. The present value of any  remaining guaranteed payments will be based on the total Income Payments as of the date of  the calculation. The Company will determine the interest rate used in this present value  calculation, but in no instance will it be greater than one (1) percentage point higher than the  rate used to calculate the initial Income Payment.    ADDITIONAL INCOME OPTIONS. The Company may make available other Income Options. 

 

  RILA292NY 29  INCOME PROVISIONS (CONT'D)    OWNER'S DEATH ON OR AFTER THE INCOME DATE. If any Owner who is not also an  Annuitant dies on or after the Income Date, any remaining Income Payments due will continue  at least as rapidly as the payment method in effect as of the date of the Owner's death. After the  death of the last surviving Joint Owner on or after the Income Date, any remaining Income  Payments will be paid to the Beneficiary.    ANNUITANT'S DEATH ON OR AFTER THE INCOME DATE. Upon the death of the Annuitant  (and Joint Annuitant, if applicable) on or after the Income Date, the death benefit, if any, will be  as specified in the Income Option in effect. Any life-contingent Income Payments cease on the  death of the Annuitant (and Joint Annuitant, if applicable). Any amounts due after an Annuitant's  death will continue to be paid at least as rapidly as the payment method in effect as of the date  of the Annuitant's death.    BENEFICIARY'S ENTITLEMENT TO INCOME PAYMENTS AFTER THE INCOME DATE.  Upon the death of any Owner, the Company will pay any remaining Income Payments due to  Primary Beneficiaries or, if none exist, to the Contingent Beneficiaries, in equal shares (the  "default allocation") unless You have designated otherwise (the "designated allocation"). A  Beneficiary that dies before or within ten (10) days (or different period as prescribed by  applicable law) of Your death is not entitled to remaining Income Payments due; in that  circumstance, the Company will pay any remaining Income Payments due the deceased  Beneficiary to surviving Beneficiaries in the same proportion as the designated allocation or, if  applicable, the default allocation. A Contingent Beneficiary has no rights unless the Contingent  Beneficiary survives all Primary Beneficiaries who would have been entitled to receive  payments under the Contract had they survived. If no Beneficiary survives You, the Company  will pay remaining Income Payments to Your estate.  

 

  RILA292NY 30  TERMINATION PROVISIONS    This Contract terminates and all Contract benefits, will end on the earliest of:  1. the date You take a total withdrawal;  2. the date the Contract Value is reduced to zero for any reason, or;  3. the date upon which the entire interest in the Contract has been distributed. Distributions  may be made in whole or in part after the Income Date, after Due Proof of the relevant death  and a claim form in Good Order has been received by the Company, and/or under a  supplemental contract evidencing the interest in the contract to be distributed.nr290final11-14x22forfil

Linking/BIN/Brokerage Acct. Number (if applicable) Page 1 of 11 NR290 06/23 Home Office:  Purchase, NY 10577 www.jackson.com NR290 Jackson of NY   pre-assigned Contract Number (if applicable) APPLICATION FOR AN INDIVIDUAL SINGLE PREMIUM DEFERRED REGISTERED INDEX-LINKED ANNUITY (RILA290NY/RILA292NY) Primary Owner First Name Middle Name Last Name Non-Natural Owner/Entity Name (if applicable) Social Security Number Phone Number (include area code) Individual/Joint Corporation/Pension PlanCustodian Government Entity Tax ID Numberor Trust Physical Address Line 1  Physical Address City State ZIP Mailing Address City State ZIP Physical Address Line 2 Mailing Address Line 1 Mailing Address Line 2 (mm/dd/yyyy)Date of Birth Email Address Country of Residence Sex Male FemaleU.S. Citizen Yes No JACKSON MARKET LINK PRO   II (06/23)  (no P.O. Boxes) Jackson National Life Insurance Company of New York Customer Care: 800-599-5651 Fax: 800-576-8383 Email: customercare@jackson.com First Class Mail: P.O. Box 30314 Lansing, MI 48909-7814 Overnight Mail: 1 Corporate Way Lansing, MI 48951 PLEASE PRINT  CLEARLY Type of Ownership: 

 

Page 2 of 11 NR290 06/23NR290 First Name Middle Name Last Name Relationship to Owner Social Security Number Phone Number (include area code) Physical Address Line 1 Physical Address City State ZIP Physical Address Line 2 First Name Middle Name Last Name Social Security Number Physical Address Line 1 Physical Address City State ZIP Physical Address Line 2 Date of Birth (mm/dd/yyyy) First Name Middle Name Last Name Relationship to Primary Annuitant Social Security Number Phone Number (include area code) Physical Address Line 1  Physical Address City State ZIP Physical Address Line 2 Joint Owner Primary Annuitant Joint Annuitant Phone Number (include area code) (mm/dd/yyyy)Date of Birth Email Address (print clearly)Date of Birth (mm/dd/yyyy) Sex Male FemaleU.S. Citizen Yes No Country of Residence Sex Male FemaleU.S. Citizen Yes No Country of Residence Sex Male FemaleU.S. Citizen Yes No Country of Residence Joint Annuitant Not Applicable (no P.O. Boxes) (no P.O. Boxes) (no P.O. Boxes) Complete this  section if  different than  Primary Owner.  If Primary  Annuitant  section is left  blank, the  Annuitant will  default to the  Primary Owner. Complete this  section if  different than  Joint Owner. If  Joint Annuitant  section is left  blank, the Joint  Annuitant will  default to the  Joint Owner. In the case of  Joint Owners,  all  correspondence  and required  documentation  will be sent to  the address of  the Primary  Owner. 

 

Page 3 of 11 NR290 06/23NR290 Beneficiary(ies) Primary % Percentage of Death Benefit First Name Middle Name Last Name Non-Natural Owner/Entity Name (if applicable) Phone Number (include area code) Physical Address Line 1 Physical Address City State ZIP Physical Address Line 2 Social Security/Tax ID Number Relationship to OwnerDate of Birth (mm/dd/yyyy) Primary % Percentage of Death Benefit First Name Middle Name Last Name Non-Natural Owner/Entity Name (if applicable) Phone Number (include area code) Physical Address Line 1 Physical Address City State ZIP Physical Address Line 2 Social Security/Tax ID Number Relationship to OwnerDate of Birth (mm/dd/yyyy) Primary % Percentage of Death Benefit First Name Middle Name Last Name Non-Natural Owner/Entity Name (if applicable) Phone Number (include area code) Physical Address Line 1 Physical Address City State ZIP Physical Address Line 2 Social Security/Tax ID Number Relationship to OwnerDate of Birth (mm/dd/yyyy) Contingent Contingent Sex Male Female Sex Male Female Sex Male Female (no P.O. Boxes) (no P.O. Boxes) (no P.O. Boxes) It is required for  Good Order  that the  Percentage of  Death Benefit  be whole  numbers and  must total  100% for each  beneficiary  type. If  Percentage of  Death Benefit is  left blank, all  beneficiaries  will receive  equal shares. Please use the  Beneficiary  Designation  Supplement  form (N3041)  for additional  beneficiaries. 

 

Tax Qualification Non-Tax Qualified Roth IRA Other: SEP Roth Conversion IRA - Traditional Stretch IRA Non-Qualified Stretch 403(b) TSA  10-Year Qualified Deferral For Stretch Deferrals, please indicate the deferral type and the deceased's information: Relationship to Current Owner/Applicant Date of Birth Date of Death  Stretch Roth IRA Premium Payment Check(s) ACH/Wire(s) $ $ Anticipated total amount from: $ $ Company Releasing Funds Account Number Full Partial Full Partial Maturity Date Transfer Type $ $ Anticipated Transfer Amount Please provide the following information if applicable: Jackson of NY to request funds IRC 1035 Exchange Direct Transfer Non-1035 Exchange Non-Direct RolloverDirect Rollover Non-Qualified Plans: All Other Plans: Internal Transfer(s)/Death Claim Proceeds External Transfer(s) In-house funding - Select one: Page 4 of 11 NR290 06/23NR290 Year:                      $ Year:                      $ Financial Professional or Owner to request funds Payment included Internal Transfer Death Claim Proceeds (mm/dd/yyyy) (mm/dd/yyyy) The Registered  Index-Linked  Annuity  Automatic  Withdrawal Request form  (NR4370) is  required if a  Stretch  qualification is  elected. External  Transfers: The  Request for  Transfer or  Exchange of  Assets form  (N3783) must  be submitted if  Jackson of NY is  to request  the release  of funds. For more than  two account  transfers,  please provide  account  information on  the Letter of  Instruction form  (N4250) and  submit with  application. Select payment method. Must select at least one: For IRA - Traditional or Roth IRA Tax Qualifications, please indicate tax contribution year(s) and amount(s). If the  year(s) is (are) not indicated, Jackson of NY will default to the current tax year. We reserve the right to refuse a Premium payment that is comprised of multiple payments over a period of  time. If we permit you to make multiple payments as part of your Premium payment, the Contract will not  be issued until all such payments are received. We reserve the right to hold such multiple payments in a  non-interest bearing account until the Issue Date.  

 

Page 5 of 11 NR290 06/23NR290 Statement Regarding Replacement of Existing Policies or Annuity Contracts Telephone/Electronic Transaction Authorization Annuitization/Income Date Specify Income Date (mm/dd/yyyy) Do you intend to replace or change an existing life insurance policy or annuity contract? No Yes It is required for  Good Order  that this entire  section be  completed. By checking " Yes," I (we) authorize Jackson of NY to accept instructions to initiate or discontinue Periodic Reallocation Programs (Automatic Rebalancing, End-Term Performance Lock), initiate an Intra-Term Performance Lock or transfer Contract values between Contract Options via telephone, internet, or other electronic medium from me, or in the case of Joint Owners, from any Joint Owner, or from my (our) Financial Professional, subject to Jackson of NY's administrative procedures. Do you consent to Telephone/Electronic Transaction Authorization?          Yes           No Jackson of NY has administrative procedures that are designed to provide reasonable assurances that telephone/electronic transaction authorizations are genuine. If Jackson of NY fails to employ such procedures, it may be held liable for losses resulting from a failure to use such procedures. I (We) release Jackson of NY, its  affiliates, subsidiaries, and agents from all damages related in any way to its acting upon any unauthorized  telephone/electronic instruction, where Jackson of NY's administrative procedures were properly followed. I (We)  understand and agree that Jackson of NY reserves the right to terminate or modify these telephone/electronic  privileges at any time, without cause and without notice to me (us). To give consent to initiate partial withdrawals via telephone, internet, or other electronic medium, please  complete the Registered Index-Linked Annuity Telephone/Electronic Authorization Request form (NR3782). If no election  is made,  Jackson of NY  will default to  " No." If an Annuitization/Income Date is not specified, Jackson of NY  will default to the Latest Income Date as shown in the  Contract. If replacing,  please provide  the Jackson of  NY  pre-assigned  Contract  number. Please complete all necessary forms as required by New York Regulation 60.  Jackson of NY pre-assigned Contract number:  

 

Page 6 of 11 NR290 06/23NR290 Contract Options Periodic Reallocation Programs PLEASE NOTE: Contract Options are subject to availability. 1-Year    %Index Account Options S&P 500   Index BUFFER 10% 20% Cap Performance Boost Performance Trigger Cap 3-Year    % 6-Year    % 1-Year    %Index Account Options Russell 2000   Index BUFFER 10% 20% Cap Performance Boost Performance Trigger Cap 3-Year    % 6-Year    % 1-Year    %Index Account Options MSCI EAFE Index BUFFER 10% 20% Cap Performance Boost Performance Trigger Cap 3-Year    % 6-Year    % Automatic Rebalancing End-Term Performance Lock Tell us how  you want  your annuity  Premium  invested.  Whole percentages only. TOTAL  ALLOCATION MUST EQUAL  100%. CONTRACT OPTIONS CONTINUED ON PAGE 7. Certain  broker-dealers  may limit the  Index Account  Options and/or  Fixed Account  under the  Contract. Please  see Applicant  Acknowledg- ments on page  9. Automatically transfer any positive Index Adjustments from the Index Account Option(s) to the 1-year Fixed Account Option on the Index Account Option Term Anniversary. Automatically rebalance Index Account Option and Fixed Account Option allocations on the Index Account Option Term Anniversary and/or the Contract Anniversary, as applicable, where more than one Contract Option has been elected. Note: Automatic Rebalancing will occur on an annual basis on each Contract Anniversary. Only eligible  Contract Options will proportionally reallocate based on the percentages You provide. Index Account Options  are only eligible to be included in rebalancing on their Index Account Option Term Anniversary. Please read the Important Information related to Periodic Reallocation Programs in the Notice to Applicant section on page 9. May select only one Periodic Reallocation Program. 

 

Page 7 of 11 NR290 06/23NR290 Contract Options (continued from page 6)PLEASE NOTE: Contract Options are subject to availability. 1-Year    %Index Account Options MSCI Emerging Markets Index BUFFER 10% 20% Cap Performance Boost Performance Trigger Cap 3-Year    % 6-Year    % 1-Year    %Index Account Options MSCI KLD 400 Social Index BUFFER 10% 20% Cap Performance Boost Performance Trigger Cap 3-Year    % 6-Year    % Fixed Account Option Fixed Account 1-Year    % Tell us how  you want  your annuity  Premium  invested. Whole percentages only. TOTAL  ALLOCATION MUST EQUAL  100%. Certain  broker-dealers  may limit the  Index Account  Options and/or  Fixed Account  under the  Contract. Please  see Applicant  Acknowledg- ments on page  9. 

 

Page 8 of 11 NR290 06/23NR290 Electronic Delivery Authorization Do you consent to electronic delivery of documents? Yes No Transaction confirmations Other Contract-related correspondence ALL DOCUMENTS Contract and prospectus Disclosure documents Annual statements If no election  is made,  Jackson of NY  will default to  " No." Check the box(es) next to the type of documents you wish to receive electronically. If electronic delivery is  authorized but no document type is selected, the selection will default to "All Documents." Please provide  one email  address and  print clearly. If you authorize  electronic  delivery but do  not provide an   email address  or the address  is illegible,  electronic  delivery  will  not be initiated. Registration at  jackson.com is  required for  electronic  delivery of  documents. Authorizing   electronic  delivery of  annual  statements will  automatically  enroll you to  receive  quarterly  summaries.  Quarterly  summaries are  only available  via electronic  delivery. My email address is:                                                                                                                                                I (We) will notify the Company of any new email address. Jackson of NY offers the ability to receive documents via electronic delivery (e-delivery). This disclosure will help you  decide whether you would like to consent to e-delivery. If you do not consent to e-delivery, you will continue to  receive documents via physical mail. Please read this carefully and in its entirety. If you consent, Jackson of NY will provide documents related to your Contract by e-delivery. Jackson of NY will  provide documents via e-delivery as long as it is consistent with applicable state and federal law, delivery  preferences are updated, and the Contract is still active. For security purposes, if your jackson.com account is not  accessed within 18 months, we may remove your registration and change your delivery method to physical mail.  Any document we send by e-delivery that complies with applicable law, will have the same force and effect as if  that document were sent in a paper form.  This consent covers all electronic documents and communications as related to any eligible* Contract(s) through  the Company, which may include, but are not limited to, applications, supplements, Contract delivery notices,  Contracts, prospectuses, prospectus supplements, confirmation statements, annual or quarterly statements, and  any Contract-related correspondence including claims and servicing correspondence. You may continue to receive  some paper documents for compliance reasons. When additional document types are available, they will be sent  via e-delivery automatically if consent was previously provided.  Please note election for electronic tax documents must be completed once you log onto your account on  jackson.com. The Company will notify you of the availability of your document(s) by email or attach your document(s) within the  email. Jackson of NY will not charge a fee for this service. Please make sure a current email address is provided and  update your profile on jackson.com if your email address changes. Please login to your Contract on jackson.com  and access your Filing Cabinet to view your document(s) or click the link that will be provided in the email  notification in order to view the material.  To successfully receive electronic transmissions, your electronic device must have internet access, an active email  account, Adobe Acrobat Reader, and pop-up blockers turned off. Please note some internet browsers may not  function well with jackson.com. If a browser error occurs, use a different internet browser. If you do not already  have Adobe Acrobat Reader, it can be downloaded for free from www.adobe.com.  Paper copies of documents may be requested by calling the Customer Care Center, whether or not you consent or  revoke your consent for e-delivery, at any time for no additional charge. Consent can be revoked by updating your  preferences on jackson.com or by calling the Customer Care Center. If you choose to enroll in e-delivery, you consent to the terms outlined above for electronic transmissions.  *Eligible refers to Contracts that are currently inforce or that will be inforce and are available for electronic transmission.  

 

Applicant Acknowledgments NR290 Page 9 of 11 NR290 06/23 Notice to Applicant 1. I (We) hereby represent to the best of my (our) knowledge and belief that each of the statements and  answers contained in this application are true, complete and correctly recorded. 2. I (We) acknowledge that all statements made by, or under the authority of the applicant, for the issuance of the Contract, are deemed representations and not warranties. 3. I (We) certify that the Social Security or Taxpayer Identification number(s) shown above is (are) correct. 4. I (We) certify that the date of birth of the Owner and any Joint Owner, primary spousal Beneficiary, Annuitant  or Joint Annuitant, if applicable, stated in this application is (are) true and correctly recorded. 5. I understand the restrictions imposed by 403(b)(11) of the Internal Revenue Code. I understand the  investment alternatives available under my employer's 403(b) plan, to which I may elect to transfer my  contract value. 6. I (We) understand that while the values of the Contract may be affected by an external Index, the Contract  does not participate in any stock or equity investment. 7. I (We) understand that the capping component in this Contract may limit the Index Adjustment credited to  the Index Account Option value on each Index Account Option Term Anniversary, regardless of the  performance of the Indices. 8. I (We) have received the applicable current Buffers, Caps/Rates and any other Index Adjustment Factors  associated with this Contract. 9. I (We) understand that to the extent I (we) have been permitted to make a Premium payment comprised of  multiple payments over a period of time, my (our) Contract will not be issued until all such payments are  received, and all Premium payments will be held in a non-interest bearing account until the date my (our)  Contract is issued. 10. I (We) understand that the Company may restrict transfers to the Index Account Options at any time, on a  non-discriminatory basis, if the yield on investment or cost of hedging would not support the minimum  guarantees of the Index Account Option(s), as long as one (1) Index Account Option remains available for  allocation. The Company will not restrict Premium allocation and transfers to the Fixed Account Option(s) at  any time. 11. I (We) have been given a current prospectus for this registered index-linked annuity product.  12. I (We) understand that Jackson of NY offers other annuities with similar features, limitations, minimum  Caps/Rates and charges. I (We) have discussed the alternatives with my (our) Financial Professional, including  that similar products with higher or lower Caps/Rates may be available through other broker-dealers. 13. I (We) understand and acknowledge that amounts payable under the Contract may be subject to a  Withdrawal Charge, if applicable, which may cause the values to decrease if withdrawn prior to a  specified date or dates as stated in the Contract. 14. I (We) acknowledge and represent that I (we) have executed this application, and that my (our) signature(s)  below (including my (our) electronic signature(s)) is (are) my (our) true and valid signature(s). I (We) further  authorize Jackson of NY to accept any electronic signature(s) that I (we) may make to this application. 15. I (We) understand that certain broker-dealers may limit the Contract Options available under the Contract. I  (We) have discussed these limitations with my (our) Financial Professional and have been provided with a list  of Contract Options currently available for election through my (our) broker-dealer.  I (We) understand that  any application including an election of a Contract Option not available through my (our) broker-dealer will  not be accepted. I (We) understand that the Contract Options not available through my (our) broker-dealer  may be available through other broker-dealers. This application will be attached to and made part of the Contract. Important Information related to Periodic Reallocation Programs: Periodic Reallocation Programs do not ensure a profit or protect against loss. Principal value and investment return  in the Index Account Options will fluctuate with changes in the elected tracked Index. When reallocated, Index  Account Option values may be more or less than the Index Return due to the application of Index Adjustments  associated with your elected crediting method. In addition, Index Account Option values on the date reallocated  may be more or less than they were on the date of original allocation due to changes in Index Return during the  elected Index Account Option term. Please see the prospectus for additional information related to Periodic  Reallocation Programs. 

 

Page 10 of 11 NR290 06/23NR290 Owner's Signature Date Signed (mm/dd/yyyy) State Where Signed Owner's Title Date Signed (mm/dd/yyyy)Joint Owner's Signature Date Signed (mm/dd/yyyy) Date Signed (mm/dd/yyyy) Annuitant's Signature Joint Annuitant's Signature Applicant Signatures State Where Signed U.S. Tax Certifications Check this box if the IRS has notified you that you are subject to backup withholding.  (required if owned by an Entity) (if other than Owner) (if other than Joint Owner) Not FDIC/NCUA Insured    Not bank/CU guaranteed    May lose value Not a deposit    Not insured by any federal agency It is required for  Good Order  that all  applicable  parties to the  Contract sign  here. Required  replacement  form(s) must  be signed on  or before the  application  signature  date. Under penalties of perjury, I certify that: 1. My Social Security Number or Tax ID Number shown on this application is my correct taxpayer  identification number,  2. I am not subject to backup withholding,  3. I am a U.S. citizen or other U.S. person (including a U.S. resident alien), and 4. I am exempt from Foreign Account Tax Compliance Act (FATCA) reporting.  For items 3 and 4, if I am not a U.S. citizen, U.S. resident alien or other U.S. person, I am submitting the  applicable IRS Form W-8 to certify my foreign status and, if applicable, claim treaty benefits.  The Internal Revenue Service does not require your consent to any provision of this document other than  the certifications to avoid backup withholding. 

 

Financial Professional Acknowledgments and Signature NR290 Page 11 of 11 NR290 06/23 Financial Professional # 1 Signature Date Signed (mm/dd/yyyy) First Name Middle Name Last Name Email Address Business Phone Number (include area code) Jackson of NY Assigned ID Financial Professional # 2 Name Financial Professional # 3 Name Jackson of NY Assigned ID Jackson of NY Assigned ID Percentage Percentage % % Percentage % (print clearly) Extension Financial Professional # 4 Name Jackson of NY Assigned ID Percentage % Program Options A B C D Financial Institution By signing this form, I certify that: 1. I am authorized and qualified to discuss the Contract herein applied for. 2. I have reviewed all of the applicant's information, and I believe that my recommendation to purchase this  annuity is in line with the applicant's financial situation and investment needs, and meets the appropriate  standard of care (i.e. suitability or best interest) based on the facts disclosed by said applicant. I also attest that I  have provided the applicant with all pertinent information about the product, including disclosure of risks  involved, allowing the applicant to make an educated and informed decision about this purchase. Based on my  completion of the required general annuity and/or Jackson of NY product training, I believe this transaction is  suitable and in the best interest of the applicant given the applicant's financial situation and needs. 3. The applicable current Buffers, Caps/Rates and any other Index Adjustment Factors associated with this Contract  have been presented and explained to the applicant(s).  4. I have not made statements that differ from this material nor have I made any promises about the expected  future Index Account Option values of this Contract. 5. The applicant's statement as to whether or not an existing life insurance policy or annuity contract is being  replaced or changed is true and accurate to the best of my knowledge and belief. 6. I have discussed all applicable limitations to Contract Option availability with the applicant and have provided  the applicant with a list of Contract Options currently available for election. Program Options Note: If no option is  indicated, the   designated  default will be  used.  If more than one Financial Professional is participating in a Program Option on this case, please provide the  additional Financial Professional names, Jackson of NY Assigned IDs and percentages for each (Financial Professional  # 1-4 totaling 100%). If Percentage is  left blank, all  Financial  Professionals  will receive  equal shares. All Financial  Professional  certifications,  licenses and  trainings must  be completed  prior to  application  execution.

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