EX-99 2 ex99b5bgacda11050106app.htm EX. 99-B.5B GA-CDF-1105(08/06) APPLICATION

Ex. 99-B(5)(b)

 

Annuities

 

 

VARIABLE ANNUITY APPLICATION

 

ING USA Annuity and Life Insurance Company (“ING USA”)

Service Office: P.O. Box 9271, Des Moines, IA 50306-9271

Overnight Address: 909 Locust Street, Des Moines, IA 50309-2899; Phone: 800-366-0066

 

 

 

For Agent Use Only: Client's Account Number:

 

If this customer data form 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

 

Name

 

Trust Date

 

 

SSN/TIN

 

Birth Date

 

 

 

Male

 

 

Female

 

Permanent Street Address

 

 

City

 

State

 

Zip

 

 

Phone #

 

Email Address

 

 

Country of Citizenship

 

 

 

 

1(B). JOINT OWNER (Optional.)

 

Relationship to Owner

 

 

Name

 

Trust Date

 

 

SSN/TIN

 

Birth Date

 

 

 

Male

 

 

Female

 

Permanent Street Address

 

 

City

 

State

 

Zip

 

 

Phone #

 

Email Address

 

 

Country of Citizenship

 

 

 

 

2. ANNUITANT (If other than owner.)

 

Name

 

Relationship to Owner

 

 

SSN

 

Birth Date

 

 

 

Male

 

 

Female

 

Permanent Street Address

 

 

City

 

State

 

Zip

 

 

Country of Citizenship

 

 

 

 

 

 

 

 

 

GA-CDF-1105(08/06)

Page 1 of 9 – Incomplete without all pages.

Order #137872

08/07/2006

 

 

 


 

 

 

 

3(A). BENEFICIARY(S) (All fields for each Beneficiary must be completed. Complete Section 3B for custodially owned contracts.)

 

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

 

 

 

Please use the space in Section 10 if you need to list more Beneficiaries.

 

 

3(B). CUSTODIAL BENEFICIARY (Required if Joint LifePay is selected on a custodially owned contract. This sole beneficiary must be the spouse of the annuitant. All fields must be completed.)

 

Name

 

Birth Date

 

Percent

100

%

 

SSN/TIN

 

Is the sole beneficiary the spouse of the annuitant?

 

Yes

 

No

 

Address

 

 

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
Owner

 

Birth Date

 

SSN/TIN

 

Percent

 

One Primary Beneficiary

 

Mary M. Doe

 

Sister

 

03/31/1950

 

123-45-6789

 

100%

 

Two Primary Beneficiaries

Jane J. Doe

John J. Doe

Mother

Father

04/01/1940

05/01/1935

###-##-####

###-##-####

50%

50%

One Primary Beneficiary

One Contingent

Jane J. Doe

John J. Doe

Wife

Son

11/30/1923

06/18/1951

###-##-####

###-##-####

100%

100%

Estate

Estate of John Doe

Estate

N/A

67-981239

100%

 

Trust

ABC Trust

Dtd 1/1/85

Trust

N/A

44-234567

100%

Testamentary Trust1

(Trust established within the owner’s will)

Trust created by the
Last Will and Testa-

Ment of John Doe

Testamentary Trust

N/A

38-078602

100%

 

1If the Trust is terminated or if no trustee is qualified to receive the proceeds within six months of the insured’s death, then the proceeds go to the Owner or Owner’s Estate.

 

 

 


 

 

 

 

 

 

GA-CDF-1105(08/06)

Page 2 of 9 – Incomplete without all pages.

Order #137872

08/07/2006

 

 


 

 

 

4. PRODUCT SELECTION

 

 

ING Rollover Choice Variable Annuity

 

 

5. PLAN TYPE FOR NEW CONTRACT (Qualified or Non-Qualified. Select One.)

 

Non-Qualified:

 

Non-qualified

 

 

 

 

 

Non-qualified Transfer/1035 Exchange ("Like to Like" transfer)

 

 

 

Qualified:

 

IRA

 

IRA Transfer

 

IRA Rollover from Qualified Plan

 

 

 

 

 

 

 

 

 

TSA/403(b)

 

Qualified Other

 

 

 

If this is an IRA contribution, please indicate the amount and the tax year.

 

 

 

Roth IRA. If this is a transfer, provide the original conversion/establishment date and amount:

 

 

 

 

6. AVAILABLE OPTIONS

 

Death Benefit Option Packages (Select one. If no selection is made, the death benefit will default to "Option Package I".)

 

A.

 

Option Package I

 

 

 

B.

 

Option Package II

 

 

 

C.

 

Option Package III

 

Death Benefit, withdrawal options and expenses will vary depending on the Option Package chosen. Please refer to your prospectus for further details on the Option Packages available under this contract.

 

 

 

 

Optional Living Benefit (Select one.)

 

 

Minimum Guaranteed Income Benefit (MGIB)

 

 

 

ING LifePay Minimum Guaranteed Withdrawal Benefit (“LifePay”)1 (Not Available in MN.)

 

 

 

ING Joint LifePay Minimum Guaranteed Withdrawal Benefit (“Joint LifePay”)1 (Not Available in IL, MN, MS, or OR.)

 

There are specific ownership and beneficiary requirements for election of the Joint LifePay Benefit option.

 

1Funds must be allocated per LifePay and Joint LifePay requirements detailed on page 5. Read your prospectus carefully regarding details about LifePay and Joint LifePay. Applications that do not comply with these requirements will be deemed not in good order, and the contract will not be issued unitl correct investment instructions are received. If you choose LifePay or Joint LifePay, use only section 8B to complete your allocation selection.

 

7. PAYMENT INFORMATION (Make checks payable to ING USA Annuity and Life Insurance Company.)

 

Initial Premium Paid: $

 

 

Estimated amount of Transfer/1035 Exchange: $

 

 

 

 

 

 

 

GA-CDF-1105(08/06)

Page 3 of 9 – Incomplete without all pages.

Order #137872 08/07/2006

 

 


 

 

 

8A. ALLOCATION SELECTION – USE ONLY FOR STANDARD ALLOCATION (NO LIVING BENEFIT SELECTED)

 

Complete page 5, Section 8B if you have elected the LifePay or Joint LifePay Benefit Option.

 

To elect an optional DCA transfer program, allocate money to ING Liquid Assets, 6-Month DCA, or 12-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%.

 

Monthly transfer amount $________ (Maximum 1/12 of amount allocated to divisions below. Not applicable for 6-Month DCA.)

 

Variable Investments1

 

Initial

(Required)

 

DCA

(Optional)

Initial

(Required)

 

DCA

(Optional)

 

%

Fidelity® VIP Contrafund1

 

%

 

 

%

ING Solution Income1

 

%

 

%

Fidelity® VIP Equity-Income1

 

%

 

 

%

ING T. Rowe Price Diversified Mid Cap Growth1

 

%

 

%

Franklin Small Cap Value Securities1

 

%

 

 

%

ING T. Rowe Price Equity Income1

 

%

 

%

ING American Century Large Company Value1

 

%

 

 

%

ING T. Rowe Price Growth Equity1

 

%

 

%

ING American Century Select1

 

%

 

 

%

ING Thornburg Value1

 

%

 

%

ING American Century Small-Mid Cap Value1

 

%

 

 

%

ING UBS U.S. Large Cap Equity1

 

%

 

%

ING American Funds Growth1

 

%

 

 

%

ING Van Kampen Comstock Fund1

 

%

 

%

ING American Funds Growth-Income1

 

%

 

 

%

ING Van Kampen Equity and Income1

 

%

 

%

ING American Funds International1

 

%

 

 

%

ING VP Balanced1

 

%

 

%

ING Baron Small Cap Growth1

 

%

 

 

%

ING VP Financial Services1

 

%

 

%

ING Davis Venture Value1

 

%

 

 

%

ING VP Global Science and Technology1

 

%

 

%

ING Evergreen Omega1

 

%

 

 

%

ING VP Growth and Income1

 

%

 

%

ING FMR(SM) Earnings Growth1

 

%

 

 

%

ING VP Growth1

 

%

 

%

ING Fundamental Research1

 

%

 

 

%

ING VP Index Plus International Equity1

 

%

 

%

ING Goldman Sachs Capital Growth1

 

%

 

 

%

ING VP Index Plus LargeCap1

 

%

 

%

ING JPMorgan International1

 

%

 

 

%

ING VP Index Plus MidCap1

 

%

 

%

ING JPMorgan Mid Cap Value1

 

%

 

 

%

ING VP Index Plus SmallCap1

 

%

 

%

ING Legg Mason Aggressive Growth1

 

%

 

 

%

ING VP Intermediate Bond1

 

%

 

%

ING Legg Mason Value1

 

%

 

 

%

ING VP International Equity1

 

%

 

%

ING Liquid Assets1,2

 

%

 

 

%

ING VP International Value1

 

%

 

%

ING MFS Total Return1

 

%

 

 

%

ING VP LargeCap Growth1

 

%

 

%

ING OpCap Balanced Value1

 

%

 

 

%

ING VP MidCap Opportunities1

 

%

 

%

ING Oppenheimer Global1

 

%

 

 

%

ING VP Real Estate1

 

%

 

%

ING Oppenheimer Strategic Income1,2

 

%

 

 

%

ING VP Small Company1

 

%

 

%

ING PIMCO Core Bond1,2

 

%

 

 

%

ING VP SmallCap Opportunities1

 

%

 

%

ING PIMCO High Yield1

 

%

 

 

%

ING VP Strategic Allocation Conservative1

 

%

 

%

ING PIMCO Total Return1,2

 

%

 

 

%

ING VP Strategic Allocation Growth1

 

%

 

%

ING Pioneer Fund1

 

%

 

 

%

ING VP Strategic Allocation Moderate1

 

%

 

%

ING Pioneer Mid Cap Value1

 

%

 

 

%

ING VP Value Opportunity1

 

%

 

%

ING Solution 20151

 

%

 

 

%

Oppenheimer Main Street Small Cap1

 

%

 

%

ING Solution 20251

 

%

 

 

%

PIMCO VIT Real Return1

 

%

 

%

ING Solution 20351

 

%

 

 

%

Pioneer Equity-Income VCT1

 

%

 

%

ING Solution 20451

 

%

 

 

 

 

 

 

 

Fixed Investment Options3

(Not Available in WA & OR.)

 

 

%

6-Month DCA

N/A

%

 

 

%

Fixed Account 5-Year Term

N/A

%

 

%

12-Month DCA

N/A

%

 

 

%

Fixed Account 7-Year Term

N/A

%

 

%

Fixed Account 1-Year Term

N/A

%

 

 

%

Fixed Account 10-Year Term

N/A

%

 

%

Fixed Account 3-Year Term

N/A

%

 

 

 

 

 

 

 

1 The available share class is subject to service and/or 12b-1 fees.

2 These portfolios are "special funds." Transfers to and from and amounts invested in these portfolios may affect death benefit and living benefit guarantees.

3 May not be available in all states. Read the appropriate Prospectus and any Prospectus Supplements for more information.

 

 

 

 

 

GA-CDF-1105(08/06)

Page 4 of 9 – Incomplete without all pages.

Order #137872 08/07/2006

 

 


 

 

 

8B. ALLOCATION SELECTION – USE IF YOU HAVE ELECTED THE LIFEPAY OR JOINT LIFEPAY BENEFIT OPTION

 

Complete page 4, Section 8A if you did not elect the LifePay OR Joint LifePay Benefit Option.

 

Enter allocations in whole percentages according to the following options. Dollar Cost Averaging (DCA) allocations also must follow the option limitations.

 

To elect an optional DCA transfer program, allocate money to either 6-Month DCA or 12-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%.

 

Monthly transfer amount $_____________ (Maximum 1/12 of amount allocated to divisions below. Not applicable for 6-Month DCA.)

 

 

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 and Other Funds. However, at least 20% of the account value must be invested in LifePay Fixed Allocation Fund.

 

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.

 

Accepted Funds

 

Initial

(Required)

 

Variable Investments1,3

DCA

(Optional)

Initial

(Required)

Fixed Investments3,4

(Not Available in WA & OR)

DCA

(Optional)

 

%

ING Solution 2015

 

%

 

 

%

6-Month DCA

N/A

%

 

%

ING Solution 2025

 

%

 

 

%

12-Month DCA

N/A

%

 

%

ING Solution 2035

 

%

 

 

%

Fixed Account 1-Year Term

N/A

%

 

%

ING Solution Income Portfolio

 

%

 

 

%

Fixed Account 3-Year Term

N/A

%

 

%

ING Liquid Assets2

 

%

 

 

%

Fixed Account 5-Year Term

N/A

%

 

 

 

 

 

 

 

%

Fixed Account 7-Year Term

N/A

%

 

 

 

 

 

 

 

%

Fixed Account 10-Year Term

N/A

%

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 Funds must be invested in the LifePay Fixed Allocation Fund.

______

%

ING VP Intermediate Bond1

_____

%

 

Other Funds1,3

 

%

Fidelity® VIP Contrafund1

 

%

 

 

%

ING T. Rowe Price Equity Income1

 

%

 

%

Fidelity® VIP Equity-Income1

 

%

 

 

%

ING T. Rowe Price Growth Equity1

 

%

 

%

Franklin Small Cap Value Securities1

 

%

 

 

%

ING Thornburg Value1

 

%

 

%

ING American Century Large Company Value1

 

%

 

 

%

ING UBS U.S. Large Cap Equity1

 

%

 

%

ING American Century Select1

 

%

 

 

%

ING Van Kampen Comstock1

 

%

 

%

ING American Century Small-Mid Cap Value1

 

%

 

 

%

ING Van Kampen Equity and Income1

 

%

 

%

ING American Funds Growth1

 

%

 

 

%

ING VP Balanced1

 

%

 

%

ING American Funds Growth-Income1

 

%

 

 

%

ING VP Financial Services1

 

%

 

%

ING American Funds International1

 

%

 

 

%

ING VP Global Science and Technology1

 

%

 

%

ING Baron Small Cap Growth1

 

%

 

 

%

ING VP Growth and Income1

 

%

 

%

ING Davis Venture Value 1

 

%

 

 

%

ING VP Growth1

 

%

 

%

ING Evergreen Omega1

 

%

 

 

%

ING VP Index Plus International Equity1

 

%

 

%

ING FMR(SM) Earnings Growth1

 

%

 

 

%

ING VP Index Plus LargeCap1

 

%

 

%

ING Fundamental Research1

 

%

 

 

%

ING VP Index Plus MidCap1

 

%

 

%

ING Goldman Sachs Capital Growth1

 

%

 

 

%

ING VP Index Plus SmallCap1

 

%

 

%

ING JPMorgan International1

 

%

 

 

%

ING VP International Equity1

 

%

 

%

ING JPMorgan Mid Cap Value1

 

%

 

 

%

ING VP International Value1

 

%

 

%

ING Legg Mason Aggressive Growth1

 

%

 

 

%

ING VP LargeCap Growth1

 

%

 

%

ING Legg Mason Value1

 

%

 

 

%

ING VP MidCap Opportunities1

 

%

 

%

ING MFS Total Return1

 

%

 

 

%

ING VP Real Estate1

 

%

 

%

ING OpCap Balanced Value1

 

%

 

 

%

ING VP Small Company1

 

%

 

%

ING Oppenheimer Global1

 

%

 

 

%

ING VP SmallCap Opportunities1

 

%

 

%

ING Oppenheimer Strategic Income1,2

 

%

 

 

%

ING VP Strategic Allocation Conservative1

 

%

 

%

ING PIMCO Core Bond1,2

 

%

 

 

%

ING VP Strategic Allocation Growth1

 

%

 

%

ING PIMCO High Yield1

 

%

 

 

%

ING VP Strategic Allocation Moderate1

 

%

 

%

ING PIMCO Total Return1,2

 

%

 

 

%

ING VP Value Opportunity1

 

%

 

%

ING Pioneer Fund1

 

%

 

 

%

Oppenheimer Main Street Small Cap1

 

%

 

%

ING Pioneer Mid Cap Value1

 

%

 

 

%

PIMCO VIT Real Return1

 

%

 

%

ING Solution Income1

 

%

 

 

%

Pioneer Equity-Income VCT1

 

%

 

%

ING T. Rowe Price Diversified Mid Cap Growth1

 

%

 

 

 

 

 

 

 

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.

3 DCA does not ensure a profit or guarantee against loss in a declining market.

4 May not be available in all states. Read the appropriate Prospectus and any Prospectus Supplements for more information.

 

 

 

 

GA-CDF-1105(08/06)

Page 5 of 9 – Incomplete without all pages.

Order #137872 08/07/2006

 


 

 

 

 

10. SPECIAL REMARKS

 

 

 

 

 

 

 

 

 

 

11. REPLACEMENT

 

 

Yes

 

No

Do you currently have any existing annuity or life insurance policies or coverage?

 

 

Yes

 

No

 

 

Will this contract replace any life insurance policy or annuity contract in this or any other company?

If “Yes”, please identify each policy or contract and the issuing company.

 

Company ____________________________________________ Policy/Contract # ___________________________________

 

Company ____________________________________________ Policy/Contract # ___________________________________

 

Company ____________________________________________ Policy/Contract # ___________________________________

 

Company ____________________________________________ Policy/Contract # ___________________________________

 

 

If either or both of the questions in this section are answered “Yes”, please complete and return with this form a copy of any state replacement form(s), as applicable.

 

 

12. TELEPHONE/ELECTRONIC TRANSMISSION AUTHORIZATION

 

I authorize ING USA to act upon reallocation instructions, given by electronic means or voice command from the agent named in section 15 and/or the following individuals listed below upon furnishing their Social Security Number or alternative identification number.

 

I authorize an individual (including an agent), the Owner must initial: _______________

 

Provide the name and Social Security Number of other authorized individuals below1:

 

Name

 

SSN

 

Name

 

SSN

 

 

Neither ING USA nor any person authorized by ING USA will be responsible for any claim, loss, liability or expense if the company or authorized person acts in good faith in reliance upon this authorization in connection with oral/electronic instructions. ING USA 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 ING USA in writing of a change in instructions. ING USA may discontinue or limit this privilege at any time.

 

1If a Social Security Number/Tax ID Number is not provided, the proposed individual will not be authorized for certain transactions.

 

 

 

 

GA-CDF-1105(08/06)

Page 6 of 9 – Incomplete without all pages.

Order #137872 08/07/2006

 

 


 

 

 

13. 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, or within 30 days if you are 65 years of age or older on the date of the application for the annuity, after the day 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 containing false, incomplete, or misleading 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 fact material thereto commits a 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.

 

Washington: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

 

 

 

 

 

 

 

 

GA-CDF-1105(08/06)

Page 7 of 9 – Incomplete without all pages.

Order #137872 08/07/2006

 

 


 

 

 

14. APPLICANT SIGNATURES AND ACKNOWLEDGEMENTS

(Please read carefully, fill in all requested information, 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 may be 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.

 

The Annuity applied for does not take effect until ING USA Annuity and Life Insurance Company receives the premium payment. Make checks payable ONLY to ING USA Annuity and Life Insurance Company. Do not make checks payable to the agent, an agency or other company.

 

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 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.

 

I understand that IRAs and other qualified plans already provide tax deferral like that provided by the contract. For an additional cost, the contract provides additional features and benefits, including death benefits and the ability to receive a lifetime income. I should not purchase a qualified contract unless I want these benefits, taking into account their cost.

 

In certain circumstances, Fixed Allocation Fund Automatic Rebalancing may result in a reallocation into the Fixed Allocation Fund, even if you have not previously been invested in it. By electing to purchase the ING LifePay or Joint LifePay option (if chosen), you are providing ING USA Annuity and Life Insurance Company with direction and authorization to process these transactions, including reallocations into the Fixed Allocation Fund. You should not purchase the LifePay or Joint LifePay option if you do not wish to have your contract value reallocated in this manner.

 

I also represent that the Social Security Number or Tax Identification Number shown on this form is correct.

 

 

Owner Signature

 

 

Signed at (City, State)

 

Date

 

 

Joint Owner Signature (if applicable)

 

 

 

Signed at (City, State)

 

Date

 

 

Annuity Signature (if other than owner)

 

 

Signed at (City, State)

 

Date

 

 

 

 

 

 

 

 

 

 

GA-CDF-1105(08/06)

Page 8 of 9 – Incomplete without all pages.

Order #137872 08/07/2006

 

15. AGENT INFORMATION AND SIGNATURE

 

Does the applicant have existing individual life insurance policies or annuity contracts?

 

Yes

 

No

 

Do you have any reason to believe that the contract applied for will replace any existing annuity or life insurance coverage?

 

Yes

 

No (If "Yes", complete and attach a copy of any state replacement forms that apply.)

If either of both of the questions in the section are answered “Yes”, please complete and return with this form a copy of any state replacement form(s), as applicable.

 

If your state has adopted the NAIC Model Replacement Regulation or other state specific replacement regulations, 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 11 or in this Section 15 are answered "Yes", you must provide a replacement notice.)

 

 

Complete any required state specific paperwork?

 

By signing below you certify: 1) replacement questions were answered, 2) any sales material was shown to the applicant and a copy was left with the applicant, 3) you used only insurer-approved sales material, 4) you have not made statements that differ from the sales material, and 5) 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.)

 

Comp

 

Compensation Alternative

 

 

Option A

 

Comp

 

 

Check here if there is more than one agent on this contract.

 

Split for Agent #1

 

%, Agent #2

 

%, Agent #3

 

%

 

Please note: Compensation will be split equally if no percentages are indicated. Partial percentages will be rounded up. Agent #1 will be given the highest percentage in the case of unequal percentages. Agent #1 will receive all correspondence regarding the policy.

 

Comp

 

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-1105(08/06)

Page 9 of 9 – Incomplete without all pages.

Order #137872 08/07/2006