Allianz Life Insurance Company of New York Home Office: New York, NY

1633 Broadway, 42^nd Floor

New York, NY 10019-7585

Administrative Office:

NW 5990

PO Box 1450

Minneapolis, MN 55485-5990

800.542.5427

Owner
Individual Owner first name	MI	Last name	Jr., Sr., III

Mailing address			Email address
City	State	ZIP code		Home telephone number

City		State	ZIP code	Cell phone number
Gender Male              Female	Date of birth (mm/dd/yyyy)		Are you a non-resident alien?                                                                    Yes            No (If yes, then you are not eligible for this product.)

First name	MI	Last name				Jr., Sr., III
Mailing address				Email address
City		State	ZIP code		Home telephone number
Gender Male              Female	Date of birth (mm/dd/yyyy)		Are you a non-resident alien?                                                                    Yes            No (If yes, then you are not eligible for this product.)
Relationship to Owner Spouse under a legally recognized marriage                                                                                                                                        Other:				Social Security Number/TIN

First name	MI	Last name				Jr., Sr., III
Mailing address				Email address
City		State	ZIP code		Home telephone number

City			State	ZIP code		Cell phone number
Gender Male              Female	Social Security Number/TIN	Date of birth (mm/dd/yyyy)			Are you a non-resident alien?                                                                    Yes  No (If yes, then you are not eligible for this product.)

 2. Purchase Payment (This section must be completed.) Make check(s) payable to Allianz Life^® of NY

Include replacement forms if required

Method of Payment (Select all that apply)

Plan type at prior financial institution or contribution instructions:

Plan type at prior financial institution or contribution instructions:

Electronic Authorization – Allianz Life of NY accepts allocation and transfer instructions by electronic notification. Electronic authorizations include, but are not limited to, requests received by telephone, fax, email, or on our website.

•	The Index Effective Date cannot be the 29th, 30th, or 31st of a month. If the Index Effective Date would occur on the 29th, 30th, or 31st of a month, we change the Index Effective Date to be the next available Business Day.

•	If the Index Effective Date is not the Issue Date, Purchase Payments allocated to the Index Option(s) will be placed in the AZL® Government Money Market Fund until the Index Effective Date.

OR

•	Allocations must be in whole percentages (e.g. 33.3% or dollars are not permitted) which total 100%. You are allowed 12 free transfers each contract year.

•	If Purchase Payments are received before the Index Effective Date and you select an Index Option, the following will occur:

-	Your Purchase Payments will be placed in the AZL® Government Money Market Fund.

-	Then, on the Index Effective Date we will rebalance your Contract Value among your selected Allocation Options below.

•	If additional Purchase Payments are received after the Index Effective Date and you select an Index Option, then your Purchase Payment will be placed in the AZL® Government Money Market Fund until the next Index Anniversary.

•	We only allow allocations (both Purchase Payments and transfers of Contract Value) into the Index Options on the Index Effective Date and on subsequent Index Anniversaries.

•	We only allow transfers of Index Option Value from the Index Options to the Variable Options on every Index Anniversary.

•	Please see the current prospectus for Allocation Option requirements and allocation of additional Purchase Payments received after the Index Effective Date.

% AZL^® MVP Growth Index Strategy Fund

% Russell 2000^® Index with a 10% buffer

% S&P 500^® Index with a 10% buffer

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

The S&P 500^® Index is comprised of 500 stocks representing major U.S. industrial sectors.

The S&P 500^® is a product of S&P Dow Jones Indices LLC or its affiliates (“SPDJI”), and has been licensed for use by Allianz Life Insurance Company of New York (“Allianz Life of NY”). Standard & Poor’s^® and S&P 500^® are registered trademarks of Standard & Poor’s Financial Services LLC (“S&P”) and Dow Jones^® is a registered trademark of Dow Jones Trademark Holdings LLC (“Dow Jones”). The trademarks have been licensed to SPDJI and have been sublicensed for use for certain purposes by Allianz Life of NY. Allianz Life of NY products are not sponsored, endorsed, sold or promoted by SPDJI, Dow Jones, S&P, any of their respective affiliates (collectively, “S&P Dow Jones Indices”). S&P Dow Jones Indices does not make any representation or warranty, express or implied, to the owners of Allianz Life of NY products or any member of the public regarding the advisability of investing in securities generally or in Allianz Life of NY products particularly or the ability of the S&P 500^® to track general market performance. S&P Dow Jones Indices’ only relationship to Allianz Life of NY with respect

to the S&P 500^® is the licensing of the Index and certain trademarks, service marks and/or trade names of S&P Dow Jones Indices and/ or its licensors. The S&P 500^® is determined, composed and calculated by S&P Dow Jones Indices without regard to Allianz Life of NY or its products. S&P Dow Jones Indices have no obligation to take the needs of Allianz Life of NY or the owners of Allianz Life of NY products into consideration in determining, composing or calculating the S&P 500^®. S&P Dow Jones Indices is not responsible for and has not participated in the determination of the prices, and amount of Allianz Life of NY products or the timing of the issuance or sale of Allianz

Life of NY products or in the determination or calculation of the equation by which Allianz Life of NY products is to be converted into cash, surrendered or redeemed, as the case may be. S&P Dow Jones Indices have no obligation or liability in connection with the administration, marketing or trading of Allianz Life of NY products. There is no assurance that investment products based on the S&P 500^® will accurately track index performance or provide positive investment returns. S&P Dow Jones Indices LLC is not an investment advisor. Inclusion of a security within an index is not a recommendation by S&P Dow Jones Indices to buy, sell, or hold such security, nor is it considered to be investment advice.

S&P DOW JONES INDICES DOES NOT GUARANTEE THE ADEQUACY, ACCURACY, TIMELINESS AND/OR THE COMPLETENESS OF THE S&P 500^® OR ANY DATA RELATED THERETO OR ANY COMMUNICATION, INCLUDING BUT NOT LIMITED TO, ORAL OR WRITTEN COMMUNICATION (INCLUDING ELECTRONIC COMMUNICATIONS) WITH RESPECT THERETO. S&P DOW JONES INDICES SHALL NOT BE SUBJECT TO ANY DAMAGES OR LIABILITY FOR ANY ERRORS, OMISSIONS, OR DELAYS THEREIN. S&P DOW JONES INDICES MAKES NO

EXPRESS OR IMPLIED WARRANTIES, AND EXPRESSLY DISCLAIMS ALL WARRANTIES, OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OR USE OR AS TO RESULTS TO BE OBTAINED BY ALLIANZ LIFE OF NY, OWNERS OF ALLIANZ LIFE OF NY PRODUCTS, OR ANY OTHER PERSON OR ENTITY FROM THE USE OF THE S&P 500^® OR WITH RESPECT TO ANY DATA RELATED THERETO. WITHOUT LIMITING ANY OF THE FOREGOING, IN NO EVENT WHATSOEVER SHALL S&P DOW JONES INDICES BE LIABLE FOR ANY INDIRECT, SPECIAL, INCIDENTAL, PUNITIVE, OR CONSEQUENTIAL DAMAGES INCLUDING BUT NOT LIMITED TO, LOSS OF PROFITS, TRADING LOSSES, LOST TIME OR GOODWILL, EVEN

IF THEY HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES, WHETHER IN CONTRACT, TORT, STRICT LIABILITY, OR OTHERWISE. THERE ARE NO THIRD PARTY BENEFICIARIES OF ANY AGREEMENTS OR ARRANGEMENTS BETWEEN S&P DOW JONES INDICES AND ALLIANZ LIFE OF NY, OTHER THAN THE LICENSORS OF S&P DOW JONES INDICES.

The NASDAQ-100 Index^® includes 100 of the largest domestic and international non-financial securities listed on The NASDAQ Stock Market^® based on market capitalization.

The Product(s) is not sponsored, endorsed, sold or promoted by Nasdaq, Inc. or its affiliates (Nasdaq, with its affiliates, are referred to as the “Corporations”). The Corporations have not passed on the legality or suitability of, or the accuracy or adequacy of descriptions and disclosures relating to, the Product(s). The Corporations make no representation or warranty, express or implied to the owners of the Product(s) or any member of the public regarding the advisability of investing in securities generally or in the Product(s) particularly, or the ability of the Nasdaq-100 Index^® to track general stock market performance. The Corporations’ only relationship to Allianz Life Insurance Company of New York (“Licensee”) is in the licensing of the NASDAQ^®, and Nasdaq-100 Index^® registered trademarks, and

certain trade names of the Corporations and the use of the Nasdaq-100 Index^® which is determined, composed and calculated by NASDAQ without regard to Licensee or the Product(s). Nasdaq has no obligation to take the needs of the Licensee or the owners of the Product(s) into consideration in determining, composing or calculating the Nasdaq-100 Index^®. The Corporations are not responsible for and have not participated in the determination of the timing of, prices of, or quantities of the Product(s) to be issued or in the determination or calculation of the equation by which the Product(s) is to be converted into cash. The Corporations have no liability in connection with the administration, marketing or trading of the Product(s).

THE CORPORATIONS DO NOT GUARANTEE THE ACCURACY AND/OR UNINTERRUPTED CALCULATION OF THE NASDAQ-100 INDEX^® OR ANY DATA INCLUDED THEREIN. THE CORPORATIONS MAKE NO WARRANTY, EXPRESS OR IMPLIED, AS TO RESULTS TO BE OBTAINED BY LICENSEE, OWNERS OF THE PRODUCT(S), OR ANY OTHER PERSON OR ENTITY FROM THE USE OF THE NASDAQ-100 INDEX^® OR ANY DATA INCLUDED THEREIN. THE CORPORATIONS MAKE NO EXPRESS OR IMPLIED WARRANTIES, AND EXPRESSLY DISCLAIM ALL WARRANTIES

OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OR USE WITH RESPECT TO THE NASDAQ-100 INDEX^® OR ANY DATA INCLUDED THEREIN. WITHOUT LIMITING ANY OF THE FOREGOING, IN NO EVENT SHALL THE CORPORATIONS HAVE ANY LIABILITY FOR ANY LOST PROFITS OR SPECIAL, INCIDENTAL, PUNITIVE, INDIRECT, OR CONSEQUENTIAL DAMAGES, EVEN IF NOTIFIED OF THE POSSIBILITY OF SUCH DAMAGES.

The Russell 2000^® Index is an equity index that measures the performance of the 2,000 smallest companies in the Russell 3000^® Index, which is made up of 3,000 of the biggest U.S. stocks. The Russell 2000^® Index is constructed to provide a comprehensive and unbiased small-cap barometer and is completely reconstituted annually to ensure larger stocks do not affect the performance and characteristics of the true small-cap index.

The Russell 2000^® Index (the “Index”) is a trademark of Frank Russell Company (“Russell”) and has been licensed for use by Allianz Life Insurance Company of New York (“Allianz Life^® of NY”). Allianz Life of NY products are not in any way sponsored, endorsed, sold or promoted by Russell or the London Stock Exchange Group companies (“LSEG”) (together the “Licensor Parties”) and none of the Licensor Parties make any claim, prediction, warranty or representation whatsoever, expressly or impliedly, either as to (i) the results to be obtained from the use of the Index (upon which the Allianz Life of NY product is based), (ii) the figure at which the Index is said to stand at any particular time on any particular day or otherwise, or (iii) the suitability of the Index for the purpose to which it is being put in connection with the Allianz Life of NY product. None of the Licensor Parties have provided or will provide any financial or investment advice or recommendation in relation to the Index to Allianz Life of NY or to its clients. The Index is calculated by Russell or its agent. None of the Licensor Parties shall be (a) liable (whether in negligence or otherwise) to any person for any error in the Index or (b) under any obligation to advise any person of any error therein.

The EURO STOXX 50^®, Europe’s leading blue-chip index for the Eurozone, provides a blue-chip representation of supersector leaders in the Eurozone. The index covers 50 stocks from 11 Eurozone countries: Austria, Belgium, Finland, France, Germany, Ireland, Italy, Luxembourg, the Netherlands, Portugal and Spain.

STOXX Limited, Deutsche Börse Group and their licensors, research partners or data providers have no relationship to Allianz Life Insurance Company of New York (“Allianz Life^® of NY”), other than the licensing of the EURO STOXX 50^® and the related trademarks for use in connection with Allianz Life of NY products.

STOXX, Deutsche Börse Group and their licensors, research partners or data providers do not:

•	sponsor, endorse, sell or promote Allianz Life of NY products.

•	recommend that any person invest in Allianz Life of NY products or any other securities.

•	have any responsibility or liability for or make any decisions about the timing, amount or pricing of Allianz Life of NY products.

•	have any responsibility or liability for the administration, management or marketing of Allianz Life of NY products.

•	consider the needs of Allianz Life of NY products or the owners of Allianz Life of NY products in determining, composing or calculating the EURO STOXX 50 or have any obligation to do so.

STOXX, Deutsche Börse Group and their licensors, research partners or data providers give no warranty, and exclude any liability (whether in negligence or otherwise), in connection with the Allianz Life of NY products or their performance.

STOXX does not assume any contractual relationship with the purchasers of Allianz Life of NY products or any other third parties.

Specifically,

•	STOXX, Deutsche Börse Group and their licensors, research partners or data providers do not give any warranty, express or implied, and exclude any liability about:

•	The results to be obtained by Allianz Life of NY products, the owner of Allianz Life of NY products or any other person in connection with the use of the EURO STOXX 50 and the data included in the EURO STOXX 50;

•	The accuracy, timeliness, and completeness of the EURO STOXX 50 and its data;

•	The merchantability and the fitness for a particular purpose or use of the EURO STOXX 50 and its data;

•	The performance of Allianz Life of NY products generally.

•	STOXX, Deutsche Börse Group and their licensors, research partners or data providers give no warranty and exclude any liability, for any errors, omissions or interruptions in the EURO STOXX 50 or its data;

•

Under no circumstances will STOXX, Deutsche Börse Group or their licensors, research partners or data providers be liable (whether in negligence or otherwise) for any lost profits or indirect, punitive, special or consequential damages or losses, arising as a result of such errors, omissions or interruptions in the EURO STOXX 50 or its data or generally in relation to Allianz Life of NY products, even in circumstances where STOXX, Deutsche Börse Group or their licensors, research partners or data providers are aware that such loss or damage may occur.

The licensing Agreement between Allianz Life of NY and STOXX is solely for their benefit and not for the benefit of the owners of Allianz Life of NY products or any other third parties.

By signing below, I, the Owner, acknowledge and agree to the following:

•	I received a prospectus and have determined, to the best of my knowledge and belief, that the variable annuity applied for is not unsuitable for my investment objectives, financial situation, and financial needs. It is a long-term commitment to meet my financial needs and goals.

•	I understand that the Contract Value may increase or decrease depending on the investment results of the Allocation Options and that there is no guaranteed minimum Variable Account Value. Investment in the contract may result in a loss of Purchase Payments.

•	I understand that I can lose money that I allocate to the Index Options. This may result in a loss of Purchase Payments.

•	To the best of my knowledge and belief, all statements and answers in this application are complete and true.

•	No representative is authorized to modify this agreement or waive any Allianz Life of NY rights or requirements.

•	If this contract is being funded by an indirect rollover, I have complied with the requirement that only one rollover is permitted within a one year period from all of the IRAs I own.

As the authorized signer, please sign your name and date below in the appropriate space or we will not be able to process your request.

Signed at (City and State)

&	Contract owner’s signature:                                                                                                                                               Date:

MM/DD/YYYY

&	Joint contract owner’s signature:                                                                                                                                               Date:

MM/DD/YYYY

Alternate signatures, if applicable

Notice to Financial Professional: Product training has been completed that is applicable for the state for which this sale occurred.

By signing below, the Financial Professional certifies to the following:

•	I am FINRA registered and state licensed for variable annuity contracts in all required jurisdictions; and I provided the Owner(s) with the most current prospectus.

•	I certify that the statements of the Owner have been correctly recorded.

Broker/dealer name (please print)

Authorized signature broker/dealer (if required) Commission options (please check one)

For information on current benefit features, restrictions or charges please review with your Financial Professional. The statement of additional information is available at www.allianzlife.com/newyork.