EX-99.B5A 2 gacdf1109appl.txt DEF VAR ANN APPLICATION ANNUITIES ING GOLDENSELECT DEFERRED VARIABLE ANNUITY APPLICATION ING USA Annuity and Life Insurance Company ING [Logo] PO Box 9271 Des Moines, IA 50306-9271 Phone: (800) 366-0066 Overnight Delivery: ING Annuities 909 Locust Street Des Moines, IA 50309-2899 -------------------------------------------------------------------------------- FOR AGENT USE ONLY: Client's Account Number:____________________________________ If this application is being signed in a state other than the owner's resident state, please specify the state where the business was solicited and the purpose of the visit. __________________________________________________________________ -------------------------------------------------------------------------------- 1(A).OWNER (Please provide supporting documentation for all non-natural owners.) Name________________________________________________________Trust Date__________ SSN/TIN________________________Birth Date____________Male____Female____ Permanent Street Address________________________________________________________ City_______________________________State____________ZIP_________________________ Phone#______________Email Address_______________________________________________ -------------------------------------------------------------------------------- 1(B). JOINT OWNER (Standard Death Benefit option only. Earnings Multiplier not available.) Relationship to Owner___________________________________________________________ Name________________________________________________________Trust Date__________ SSN/TIN________________________Birth Date____________Male____Female____ Permanent Street Address________________________________________________________ City_______________________________State____________ZIP_________________________ Phone#______________Email Address_______________________________________________ -------------------------------------------------------------------------------- 2(A). ANNUITANT (If other than owner.) Name____________________________________________________________________________ SSN/TIN________________________Birth Date____________Male____Female____ Permanent Street Address________________________________________________________ City_______________________________State____________ZIP_________________________ -------------------------------------------------------------------------------- 2(B). CONTINGENT ANNUITANT (Optional.) Name____________________________________________________________________________ SSN/TIN________________________Birth Date____________Male____Female____ Permanent Street Address________________________________________________________ City_______________________________State____________ZIP_________________________ ________________________________________________________________________________ GA-CDF-1109(09/05) Page 1 of 9 Order # 137098 11/14/2005 -------------------------------------------------------------------------------- 3.BENEFICIARY(S) (Must be completed.) __Restricted Beneficiary. (If selected, complete a "Restricted Beneficiary" form and submit with this application.) Beneficiary proceeds will be split equally if no percentages are provided. -------------------------------------------------------------------------------- Primary Beneficiary Name_________________________ Birth Date_______________ Percent________________% SSN/TIN______________________ Relationship to Owner_____________________________ Address_________________________________________________________________________ -------------------------------------------------------------------------------- ___Primary ___ Contingent Beneficiary Name_________________________ Birth Date_______________ Percent________________% SSN/TIN______________________ Relationship to Owner_____________________________ Address_________________________________________________________________________ -------------------------------------------------------------------------------- ___Primary ___ Contingent Beneficiary Name_________________________ Birth Date_______________ Percent________________% SSN/TIN______________________ Relationship to Owner_____________________________ Address_________________________________________________________________________ -------------------------------------------------------------------------------- ___Primary ___ Contingent Beneficiary Name_________________________ Birth Date_______________ Percent________________% SSN/TIN______________________ Relationship to Owner_____________________________ Address_________________________________________________________________________ -------------------------------------------------------------------------------- Please use the space in Section 11 if you need to list additional Benefciaries. -------------------------------------------------------------------------------- SAMPLE BENEFICIARY DESIGNATIONS Be sure to use given names such as "Mary M. Doe", not "Mrs. John Doe", and include the address and relationship of the beneficiary or beneficiaries to the owner. The following designations may be helpful to you: --------------------------- ----------------------- ---------------------- ----- Name Relationship to Percent Owner --------------------------- ----------------------- ---------------------- ----- One Primary Benefciary Mary M. Doe Sister 100% --------------------------- ----------------------- ---------------------- ----- Two Primary Benefciaries Jane J. Doe Mother 50% John J. Doe Father 50% --------------------------- ----------------------- ---------------------- ----- One Primary Benefciary Jane J. Doe Wife 100% One Contingent John J. Doe Son 100% --------------------------- ----------------------- ---------------------- ----- Estate Estate of John Doe Estate 100% --------------------------- ----------------------- ---------------------- ----- Trust ABC Trust Dtd 1/1/85 Trust 100% --------------------------- ----------------------- ---------------------- ----- Testamentary Trust(Trust Trust created by the Last Testamentary Trust 100% established within the Will and Testament of owner's will) John Doe --------------------------- ----------------------- ---------------------- ----- ________________________________________________________________________________ GA-CDF-1109(09/05) Page 2 of 9 Order # 137098 11/14/2005 -------------------------------------------------------------------------------- 4. INITIAL INVESTMENT Please make all checks payable to ING USA Annuity and Life Insurance Company. ___Initial Premium Paid $_______________________________________________________ ___Estimated amount of Transfer/1035 Exchange $_________________________________ -------------------------------------------------------------------------------- 5. PRODUCT SELECTION(Must select one.) ___ Premium Plus ___ ES II ___ Landmark ___ Access -------------------------------------------------------------------------------- DEATH BENEFIT OPTION (Select One. If a death benefit is not chosen, the death benefit will be the Standard Death Benefit.) ___Standard (This is the only benefit option available to Joint Owners.) ___Annual Ratchet (Available in MA, OR, and WA.) ___Quarterly Ratchet (Available in AL, AK, AR, AZ, CA, CO, CT, DE, DC, FL, GA, HI, ID, IL, IN, IA, KS, KY, LA, ME, MD, MI, MN, MS, MO, MT, NE, NV, NH, NJ, NM, NC, ND, OH, OK, PA, RI, SC, SD, TN, TX, UT, VT, VA, WI, WV, and WY.) ___MAX 7 (In the state of WA this benefit is named MAX 5.5) (Available in MA, OR, and WA.) ___MAX 7% Solution (Available in AL, AK, AR, AZ, CA, CO, CT, DE, DC, FL, GA, HI, ID, IL, IN, IA, KS, KY, LA, ME, MD, MI, MN, MS, MO, MT, NE, NV, NH, NJ, NM, NC, ND, OH, OK, PA, RI, SC, SD, TN, TX, UT, VT, VA, WI, WV, and WY.) -------------------------------------------------------------------------------- OPTIONAL EARNINGS MULTIPLIER ___Earnings Multiplier Benefit Rider (Not available for Joint Owners or in the state of WA.) -------------------------------------------------------------------------------- OPTIONAL LIVING BENEFIT (May select one.) ___Minimum Guaranteed Income Benefit (MGIB) ___LifePay (Available in AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MD, ME, MI, MO, MS, MT, NC, ND, NH, NJ, NM, NV, OH, OK, PA, RI, SC, SD, TN, TX, VA, VT, WA, WI, WV, and WY.) Funds must be allocated per LifePay requirements detailed on page 6. Read your prospectus carefully regarding details about LifePay. Applications that do not comply with these requirements will be deemed not in good order, and the contract will not be issued until correct investment instructions are received. -------------------------------------------------------------------------------- 6. TELEPHONE AUTHORIZATION I authorize ING USA Annuity and Life Insurance Company (the Company) to act upon instructions given by electronic means or voice command from the agent that signs in section 14 and/or the following individuals listed below upon furnishing their Social Security Number or alternative identification number. To authorize the agent, owner must initial: _____________________ Provide the name and Social Security Number of other authorized individuals below: Name___________________________________ SSN/TIN_________________________________ Name___________________________________ SSN/TIN_________________________________ Neither the Company nor any person authorized by the Company will be responsible for any claim, loss, liability, or expense in connection with instructions received by electronic means or voice command from such person if the Company or other such person acted on such electronic means or voice command in good faith in reliance upon this authorization. The Company will continue to act upon this authorization until such time as the person indicated above is no longer affiliated with the broker/dealer under which my contract was purchased or until such time as I notify the Company in writing of a change in instructions. Note: If the authorized person's Social Security Number is not provided, the individual will not be authorized. ________________________________________________________________________________ GA-CDF-1109(09/05) Page 3 of 9 Order # 137098 11/14/2005 -------------------------------------------------------------------------------- 7. PLAN TYPE ___Non-Qualified ___1035 Exchange Qualified --------- ___IRA ___IRA Transfer(e.g. Trustee to Trustee transfer) ___IRA Rollover from Qualified ___SEP-IRA ___403(b) Plan ___Qualified Other______________________________________________________________ Indicate contribution amount and appropriate tax year___________________________ ___Roth IRA. If transfer, provide original conversion/establishment date and amount_____________________________________________________________ ___Simple IRA. If transfer, provide original establishment date and amount_____________________________________________________________ -------------------------------------------------------------------------------- 8. IMPORTANT NOTICE REGARDING REPLACEMENT Do you currently have any existing annuity or life insurance policies or coverage? ___Yes (Please continue below.) ___No This purchase may involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed purchases are also considered replacements. A replacement occurs when a new policy or contract is purchased and in connection with the sale you discontinue making premium payments on the existing policy or contract or an existing policy or contract is surrendered, forfeited, assigned to the replacing insurer or otherwise terminated or used in a financed purchase. A financed purchase occurs when the purchase of a new life insurance policy or an annuity contract involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values including accumulated dividends of an existing policy to pay all or part of any premium or payment due on the new policy. A financed purchase is a replacement. You should carefully consider whether a replacement is in your best interest. You will pay acquisition costs and there may be surrender costs deducted from your policy or contract. You may be able to make changes to your existing policy or contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy and may reduce the amount paid upon the death of the insured. We want you to understand the effects of replacements before you make your purchase decision and ask that you answer the following questions. 1. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract? ___Yes ___No 2. Are you considering using funds from your existing policies or contracts to pay premiums due on this new policy or contract? ___Yes ___No If you answered "Yes" to either of the above questions, please complete and return with this form a copy of any state replacement form(s), if applicable. I do not want this notice read aloud to me, _____________ (Owner/Applicants must initial here ONLY if they do not want the above notice read aloud.) ________________________________________________________________________________ GA-CDF-1109(09/05) Page 4 of 9 Order # 137098 11/14/2005 9A. ALLOCATION SELECTION - USE IF YOU HAVE NOT ELECTED THE LIFEPAY BENEFIT OPTION Complete page 6, Section 9B if you have elected the LifePay Benefit Option. To elect an optional DCA transfer program,allocate money to either ING Liquid Assets or 6-Month DCA,and indicate the funds the DCA is to go to by writing percentages in the "DCA (Optional)"columns.Enter allocations in whole percentages. The initial and DCA allocations must each total 100%. VARIABLE INVESTMENTS (1) Initial DCA Initial DCA (Required) (Optional) (Required) (Optional) ___% AIM V.I. Leisure ____% | ___% ING MFS Total Return ___% ___% Colonial Small Cap Value ____% | ___% ING MFS Utilities ___% ___% Fidelity VIP Contrafund ____% | ___% ING Oppenheimer Global ___% ___% Fidelity VIP Equity-Income ____% | ___% ING Oppenheimer Main Street ___% ___% ING AIM Mid Cap Growth ____% | ___% ING Pioneer Fund ___% ___% ING Alliance Mid Cap Growth ____% | ___% ING Pioneer Mid Cap Value ___% ___% ING American Funds Growth ____% | ___% ING PIMCO Core Bond ___% ___% ING American Funds Growth-Income ____% | ___% ING PIMCO High Yield ___% ___% ING American Funds International ____% | ___% ING Salomon Bros Aggressive Growth ___% ___% ING Baron Small Cap Growth ____% | ___% ING Salomon Bros All Cap ___% ___% ING Capital Guardian U.S. Equities ____% | ___% ING Salomon Bros Investors ___% ___% ING Capital Guardian Managed Global ____% | ___% ING T. Rowe Price Capital Appreciation ___% ___% ING Capital Guardian Small/Midcap ____% | ___% ING T. Rowe Price Equity Income ___% ___% ING Eagle Asset Capital Appreciation ____% | ___% ING UBS U.S. Allocation ___% ___% ING Evergreen Health Sciences ____% | ___% ING UBS U.S. Large Cap Equity ___% ___% ING Evergreen Omega ____% | ___% ING Van Kampen Comstock ___% ___% ING FMR Diversified Mid Cap ____% | ___% ING Van Kampen Equity and Income ___% ___% ING FMR Earnings Growth ____% | ___% ING Van Kampen Equity Growth ___% ___% ING Fundamental Research ____% | ___% ING Van Kampen Global Franchise ___% ___% ING Goldman Sachs Tollkeeper ____% | ___% ING Van Kampen Growth and Income ___% ___% ING Global Resources ____% | ___% ING Van Kampen Real Estate ___% ___% ING Janus Contrarian ____% | ___% ING VP Financial Services ___% ___% ING JPMorgan Emerging Markets Equity ____% | ___% ING VP Global Equity Dividend ___% ___% ING JP Morgan Fleming International ____% | ___% ING VP Index Plus LargeCap ___% ___% ING JPMorgan Small Cap Equity ____% | ___% ING VP Index Plus MidCap ___% ___% ING JPMorgan Value Opportunities ____% | ___% ING VP Index Plus SmallCap ___% ___% ING Julius Baer Foreign ____% | ___% ING VP Intermediate Bond ___% ___% ING Legg Mason Value ____% | ___% ING VP SmallCap Opportunities ___% ___% ING Liquid Assets ____% | ___% ING Wells Fargo Mid Cap Disciplined ___% ___% ING Marsico Growth ____% | ___% ProFund VP Bull ___% ___% ING Marsico Internatnl Opportunities ____% | ___% ProFund VP Europe 30 ___% ___% ING Mercury Large Cap Value ____% | ___% ProFund VP Rising Rates Opportunity ___% ___% ING Mercury Large Cap Growth ____% | ___% ProFund VP Small-Cap ___% ___% ING MFS Mid Cap Growth ____% | ---------------------------------------------------------------------------------------------------------- ING LIFESTYLE PORTFOLIOS (1) ___% ING Lifestyle Aggressive Growth Port.____% | ___% ING Lifestyle Moderate Growth Portfolio ___% ___% ING Lifestyle Growth Portfolio ____% | ___% ING Lifestyle Moderate Portfolio ___% ---------------------------------------------------------------------------------------------------------- FIXED INVESTMENTS (2) Enter the allocation percentage and the fixed interest period. Check availability prior to selection. | | ______% 6 Month DCA | ______%________Year Fixed ______%________Year Fixed | ______%________Year Fixed ______%________Year Fixed | ______%________Year Fixed ---------------------------------------------------------------------------------------------------------- 100 % Allocation Total (Initial and DCA (if elected) allocations must each total 100%.) ----------------------------------------------------------------------------------------------------------
1 The available share class is subject to distribution and/or service (12b-1) fees. 2 Death benefit and living benefit guarantees may be affected by amounts invested in or transferred to and from these investment options. ________________________________________________________________________________ GA-CDF-1109(09/05) Page 5 of 9 Order # 137098 11/14/2005 -------------------------------------------------------------------------------- 9B. ALLOCATION SELECTION - USE IF YOU HAVE ELECTED THE LIFEPAY BENEFIT OPTION Complete page 5, Section 9A if you did not elect the LifePay Benefit Option. Enter allocations in whole percentages according to the following options. DCA allocations also must follow the option limitations. To elect an optional DCA transfer program,allocate money to either ING Liquid Assets or 6-Month DCA, and indicate the funds the DCA is to go to by writing percentages in the "DCA (Optional)"columns. The initial and DCA allocations must each total 100%. --------------------------------------------------------------------------------------------------------- Option 1 - You may allocate entirely among Accepted Funds without restriction. Option 2 - You may elect not to allocate any account value to Accepted Funds and allocate entirely among LifePay Fixed Allocation Fund(s) and Other Funds. However, at least 20% of the account value must be invested in LifePay Fixed Allocation Fund(s). Option 3 - You may allocate among a combination of Accepted Funds, LifePay Fixed Allocation Fund(s), and Other Funds. However, at least 20% of the account value not invested in Accepted Funds must be invested in LifePay Fixed Allocation Fund(s). --------------------------------------------------------------------------------------------------------- ACCEPTED FUNDS Initial DCA Initial DCA (Required) VARIABLE INVESTMENTS (1) (Optional)| (Required) FIXED INVESTMENTS (2) (Optional) ___% ING Lifestyle Growth Portfolio ___% | ___% 6 month DCA NA % ___% ING Lifestyle Moderate Growth Portfolio ___% | ___% ____ Year Fixed NA % ___% ING Lifestyle Moderate Portfolio ___% | ___% ____ Year Fixed NA % ___% ING Liquid Assets(2) ___% | ___% ____ Year Fixed NA % --------------------------------------------------------------------------------------------------------- LIFEPAY FIXED ALLOCATION FUND(S) If you have chosen to allocate according to Option 2 or 3 above, at least 20% of the account value not invested in Accepted ___% ING VP Intermediate Bond ___% Funds must be invested in LifePay Fixed Allocation Fund(s). --------------------------------------------------------------------------------------------------------- OTHER FUNDS (1) | ___% ING MFS Mid Cap Growth ___% ___% AIM V.I. Leisure ____% | ___% ING MFS Total Return ___% ___% Colonial Small Cap Value ____% | ___% ING MFS Utilities ___% ___% Fidelity VIP Contrafund ____% | ___% ING Oppenheimer Global ___% ___% Fidelity VIP Equity-Income ____% | ___% ING Oppenheimer Main Street ___% ___% ING AIM Mid Cap Growth ____% | ___% ING Pioneer Fund ___% ___% ING Alliance Mid Cap Growth ____% | ___% ING Pioneer Mid Cap Value ___% ___% ING American Funds Growth ____% | ___% ING PIMCO Core Bond ___% ___% ING American Funds Growth-Income ____% | ___% ING PIMCO High Yield ___% ___% ING American Funds International ____% | ___% ING Salomon Bros Aggressive Growth ___% ___% ING Baron Small Cap Growth ____% | ___% ING Salomon Bros All Cap ___% ___% ING Capital Guardian U.S. Equities ____% | ___% ING Salomon Bros Investors ___% ___% ING Capital Guardian Managed Global ____% | ___% ING T. Rowe Price Capital Appreciation ___% ___% ING Capital Guardian Small/Midcap ____% | ___% ING T. Rowe Price Equity Income ___% ___% ING Eagle Asset Capital Appreciation ____% | ___% ING UBS U.S. Allocation ___% ___% ING Evergreen Health Sciences ____% | ___% ING UBS U.S. Large Cap Equity ___% ___% ING Evergreen Omega ____% | ___% ING Van Kampen Comstock ___% ___% ING FMR Diversified Mid Cap ____% | ___% ING Van Kampen Equity and Income ___% ___% ING FMR Earnings Growth ____% | ___% ING Van Kampen Equity Growth ___% ___% ING Fundamental Research ____% | ___% ING Van Kampen Global Franchise ___% ___% ING Goldman Sachs Tollkeeper ____% | ___% ING Van Kampen Growth and Income ___% ___% ING Global Resources ____% | ___% ING Van Kampen Real Estate ___% ___% ING Janus Contrarian ____% | ___% ING VP Financial Services ___% ___% ING JPMorgan Emerging Markets Equity ____% | ___% ING VP Global Equity Dividend ___% ___% ING JPMorgan Fleming International ____% | ___% ING VP Index Plus LargeCap ___% ___% ING JPMorgan Small Cap Equity ____% | ___% ING VP Index Plus MidCap ___% ___% ING JPMorgan Value Opportunities ____% | ___% ING VP Index Plus SmallCap ___% ___% ING Julius Baer Foreign ____% | ___% ING VP SmallCap Opportunities ___% ___% ING Legg Mason Value ____% | ___% ING Wells Fargo Mid Cap Disciplined ___% ___% ING Lifestyle Aggressive Growth ____% | ___% ProFund VP Bull ___% ___% ING Marsico Growth ____% | ___% ProFund VP Europe 30 ___% ___% ING Marsico Internatnl Opportunities ____% | ___% ProFund VP Rising Rates Opportunity ___% ___% ING Mercury Large Cap Value ____% | ___% ProFund VP Small-Cap ___% ___% ING Mercury Large Cap Growth ____% | --------------------------------------------------------------------------------------------------------- 100% Allocation Total (Initial and DCA (if elected) allocations must each total 100%.) ---------------------------------------------------------------------------------------------------------
1 The available share class is subject to distribution and/or service (12b-1) fees. 2 Death benefit and living benefit guarantees may be affected by amounts invested in or transferred to and from these investment options. ________________________________________________________________________________ GA-CDF-1109(09/05) Page 6 of 9 Order # 137098 11/14/2005 -------------------------------------------------------------------------------- 10. OPTIONAL ACCOUNT REBALANCING PROGRAM (May not use with DCA.) Automatic Allocation Rebalancing will occur on the last business day of the next scheduled rebalancing date. Please consult your prospectus for details regarding this feature as well as restrictions, minimum or maximum limitations, fees and other applicable information. Automatic Allocation Rebalancing does not apply to the Fixed Investments and cannot be elected if you participate in Dollar Cost Averaging. The percentages will be proportionally recalculated for subsequent reallocations if you have chosen a Fixed Allocation Election. Any subsequent reallocation, add-on or partial withdrawal you direct, other than on a pro rata basis, will terminate this program. Please rebalance my portfolio to the allocations on this application: ___ Quarterly ___Semi-Annually ___Annually -------------------------------------------------------------------------------- 11. SPECIAL REMARKS -------------------------------------------------------------------------------- 12. STATE REQUIRED NOTICES Below are notices that apply only in certain states. Please read the following carefully to see if any apply in your state. Arizona: On receiving your written request, we will provide you with information regarding the benefits and provisions of the annuity contract for which you have applied. If you are not satisfied, you may cancel your contract by returning it within 20 days after the date you receive it. Any premium paid for the returned contract will be refunded without interest. California Reg. 789.8: The sale or liquidation of any asset in order to buy insurance, either life insurance or an annuity contract, may have tax consequences. Terminating any life insurance policy or annuity contract may have early withdrawal penalties or other costs or penalties, as well as tax consequences. You may wish to consult independent legal or financial advice before the sale or liquidation of any asset and before the purchase of any life insurance or annuity contract. Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containingfalse, incomplete, ormisleading information is guilty of a felony of the third degree. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any factmaterial thereto commitsa fraudulent insurance act, which is a crime. New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated the state law. Arkansas, Washington D.C., Hawaii, Louisiana, Maine, New Mexico, Oklahoma, and Tennessee: Any person who knowingly and with intent to injure, defraud or deceive any insurance company, submits an application for insurance containing any materially false, incomplete, or misleading information, or conceals for the purpose of misleading, any material fact, is guilty of insurance fraud, which is a crime and in certain states, a felony. Penalties may include imprisonment, fine, denial of benefits, or civil damages. ________________________________________________________________________________ GA-CDF-1109(09/05) Page 7 of 9 Order # 137098 11/14/2005 13. SIGNATURES AND ACKNOWLEDGEMENTS (Please read carefully and sign below.) Important information:To help the government fight the funding for terrorism and money laundering activities,federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means to you: When you apply for an annuity, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. By signing below, I acknowledge receipt of the Prospectus. I agree that, to the best of my knowledge and belief, all statements and answers in this form are complete and true and maybe relied upon in determining whether to issue the applied for variable annuity. Only the owner and ING USA Annuity and Life Insurance Company have the authority to modify this form. Variable Annuities and the underlying series shares or securities which fund them are not insured by the FDIC or any other agency. They are not deposits or other obligations of any bank and are not bank guaranteed. They are also subject to market fluctuation, investment risk and possible loss of principal invested. I understand that when based on the investment experience of the Separate Account Division, the variable annuity cash surrender values may increase or decrease on any day and that no minimum value is guaranteed. The variable annuity applied for is in accord with my anticipated financial objectives. I understand that the value allocated to any Account subject to a Market Value Adjustment may increase or decrease if surrendered or withdrawn prior to a specified date(s) as stated in the contract. My signature certifies, under penalty of perjury, that the taxpayer identification number provided is correct. Unless and until you are otherwise notified, I am not subject to backup withholding because: I am exempt; or I have not been notified that I am subject to backup withholdings resulting from failure to report all interest dividends; or I have been notified that I am no longer subject to backup withholding. (Strike out the preceding sentence if subject to backup withholding.) The IRS does not require my consent to any provision of this document other than the certifications required to avoid backup withholding. Owner Signature_________________________________________________________________ Signed at (City, State)_______________________________Date______________________ Joint Owner Signature (if applicable)___________________________________________ Signed at (City, State)_______________________________Date______________________ Annuitant Signature (if other than owner)_______________________________________ Signed at (City, State)_______________________________Date______________________ ________________________________________________________________________________ GA-CDF-1109(09/05) Page 8 of 9 Order # 137098 11/14/2005 14. AGENT INFORMATION Do you have reason to believe that the contract applied for will replace any existing annuity or life insurance coverage? ___Yes ___No (If "Yes", return with this form a completed copy of any state replacement form(s), if applicable.) -------------------------------------------------------------------------------- Premium Plus Only: ___Producer Contract ___ING Employee Contract -------------------------------------------------------------------------------- If your state has adopted the NAIC Model Replacement Regulation, did you remember to do the following? * Provide any required replacement notice to the client and offer to read it aloud? (Note: If either of the questions in Replacement Section 8 is answered "Yes", you must provide a replacement notice.) * Complete the replacement notice for your state if another insurance contract is being replaced? * Complete any required state specific paperwork? By signing below you certify: 1) any sales material was shown to the applicant and a copy was left with the applicant, 2) you used only insurer-approved sales material, 3) you have not made statements that differ from the sales material, and 4) no promises were made about the future value of any contract elements that are not guaranteed (This includes any expected future index gains that may apply to this contract.) -------------------------------------------------------------------------------- Compensation Alternative (Select one-please verify with your Broker/Dealer that the option you select is available.): __A __B __C __D __E -------------------------------------------------------------------------------- Check here if there are multiple agents on this contract. Split: for Agent #1_________%, Agent #2________%, Agent #3____________% Please Note:Compensation will be split equally if no percentage is indicated. Partial percentages will be rounded up. Percentages must total 100%. Agent #1 will be given the highest percentage in the case of unequal percentages. Agent #1 will receive all correspondence regarding the policy. Agent #1 Print Name________________________________ Signature____________________________ SSN_______________________________________ Agent Phone__________________________ FL License #______________________________ Broker Code__________________________ Broker/Dealer Branch____________________________________________________________ Agent #2 Print Name________________________________ Signature____________________________ SSN_______________________________________ Agent Phone__________________________ FL License #______________________________ Broker Code__________________________ Broker/Dealer Branch____________________________________________________________ Agent #3 Print Name________________________________ Signature____________________________ SSN_______________________________________ Agent Phone__________________________ FL License #______________________________ Broker Code__________________________ Broker/Dealer Branch____________________________________________________________ ________________________________________________________________________________ GA-CDF-1109(09/05) Page 9 of 9 Order # 137098 11/14/2005