EX-99.B5A 3 rolloverapp.txt ING ROLLOVER CHOICE APPLICATION Golden American Life Insurance Company New Business: 151 Farmington Ave, Hartford TN21, CT, 06156-5996 Phone:800-599-8618 Retirement Solutions ING Rollover Choice Variable Annuity Customer Data Form Plan Applied For OWNER/Annuitant Male_ Female_ _ ING Retirement Solutions Name:______________ SSN# or Tax ID:___________ Rollover Choice Variable Permanent Address:____________________________ Annuity City:________________ State:____ Zip:_________ _ Other Date of Birth:_______ EMail Address:__________ Type of Contract Telephone: Home_____________ Work_____________ Qualified A. _Initial _Transfer* BENEFICIARY(S) (Please refer to prospectus _Rollover* for details) B. _ IRA _ 403(b) Complete Legal Name Social Security No. _ Roth IRA Relationship Percentage _ Other__________ C. _ Individual Primary:______________________________________ _Primary Option Package:(select one) _Contingent___________________________________ __Option Package I _Primary __Option Package II _Contingent___________________________________ __Option Package III Please attach a separate form for restricted Death Benefit, withdrawal beneficiary designations. options and expenses will vary depending on the PAYMENT INFORMATION Option Package chosen. Transfer/exchange: Estimated initial premium Please refer to your $___________________. prospectus for further Internal Exchange: $______ premium paid for details on the Option contract being exchanged. Packages available _______Initial contract date of contract being under this contract. exchanged _____________Contract number of contract being Because each series of the exchanged GET Fund is a limited time offering, please note that any initial or subsequent deposits received for the GET Fund will be allocated to the series that is then available. If no series is available, your deposit will be allocated to the Liquid Asset Series, unless otherwise specified. _Fixed Account deposit periods, to automatically transfer at maturity to available series of the GET Fund. _Guaranteed Interest division (MD & WA only),to automatically DCA at maturity to available series of the GET Fund. Dollar Cost Averaging and Pre-Authorized Check Payments are not permitted into the GET Fund. GA-CDF-1105 Page 1 of 4 01/15/2003 11541/M.P.MS.60 ALLOCATION OF INITIAL PAYMENT DOLLAR COST AVERAGING (DCA)1,3 Variable Investment Options1 _I elect DCA for a period of (Percentages must be in whole no.) ________ months. DCA program will _%AIM VI Capital Appreciation Fund4 commence immediately following _%AIM Core Equity Fund4 purchase payment. (6-12 mos. for _%AIM Premier Equity Fund4 the Guaranteed Interest Division _%Fidelity VIP Equity-Income4 (DCA Only).) _%Fidelity VIP Growth4 Monthly Transfer Amount$___________ _%Fidelity VIP II Contrafund4 From: _%Fidelity VIP II Overseas4 Source Fund:_______________________ _%Franklin Value Securities Fund4 (Enter dollar amount or whole _%GCG Core Bond Series percentage amount.) _%GCG Liquid Asset Series _AIM VI Capital Appreciation Fund4 _%GCG Total Return Series _AIM Core Equity Fund4 _%ING Alger Aggressive Growth4 _AIM Premier Equity Fund4 _%ING Alger Growth4 _Fidelity VIP Equity-Income4 _%ING Amer. Century SmallCap Value4 _Fidelity VIP Growth4 _%ING Baron SmallCap Growth4 _Fidelity VIP II Contrafund4 _%ING GET Fund _Fidelity VIP II Overseas4 _%ING Goldman Sachs Capital Growth4 _Franklin Value Securities Fund4 _%ING JP Morgan Fleming Int'l4 _GCG Core Bond Series _%ING JP Morgan MidCap Value4 _GCG Liquid Asset Series _%ING MFS Global Growth4 _GCG Total Return Series _%ING MFS Research4 _ING Alger Aggressive Growth4 _%ING MFS Capital Opportunities4 _ING Alger Growth4 _%ING MidCap VCT4 _ING Amer. Century SmallCap Value4 _%ING OpCap Balanced Value4 _ING Baron SmallCap Growth4 _%ING PIMCO Total Return4 _ING Goldman Sachs Capital Growth4 _%ING Salomon Bros Capital4 _ING JP Morgan Fleming Int'l4 _%ING Salomon Bros Investors Value4 _ING JP Morgan MidCap Value4 _%ING T. Rowe Price Growth Equity4 _ING MFS Global Growth4 _%ING UBS Tactical Asset Allocation4 _ING MFS Research4 _%ING Van Kampen Comstock Fund4 _ING MFS Capital Opportunities4 _%ING Index Plus LargeCap VP4 _ING MidCap VCT4 _%ING Index Plus MidCap VP4 _ING OpCap Balanced Value4 _%ING Index Plus SmallCap VP4 _ING PIMCO Total Return4 _%ING Growth VP4 _ING Salomon Bros Capital4 _%ING VP Growth Opportunities4 _ING Salomon Bros Investors Value4 _%ING VP International Value4 _ING T. Rowe Price Growth Equity4 _%ING VP MidCap Opportunities4 _ING UBS Tactical Asset Allocation4 _%ING International Equity VP4 _ING Van Kampen Comstock Fund4 _%ING VP SmallCap Opportunities4 _ING Index Plus LargeCap VP4 _%ING Small Company VP4 _ING Index Plus MidCap VP4 _%ING Value Opportunity VP4 _ING Index Plus SmallCap VP4 _%Janus Aspen Series Balanced4 _ING Growth VP4 _%Janus Aspen Series Flex Income4 _ING VP Growth Opportunities4 _%Janus Aspen Series Growth _ING International Equity VP4 _%Janus Aspen Series World Growth4 _ING VP MidCap Opportunities4 _%Oppenheimer Global SecuritiesVA4 _ING International Equity VP4 _%Oppenheimer Strategic BondVA4 _ING VP SmallCap Opportunities4 _%Pioneer Equity-Income VCT 4 _ING Small Company VP4 _%Pioneer Fund VCT Portfolio4 _ING Value Opportunity VP4 Fixed Investment Options _Janus Aspen Series Balanced4 Not Available in MD & WA _Janus Aspen Series Flex Income4 __%Fixed Account 1-Year Term _Janus Aspen Series Growth __%Fixed Account 3-Year Term _Janus Aspen Series World Growth4 __%Fixed Account 5-Year Term _Oppenheimer Global SecuritiesVA4 __%Fixed Account 7-Year Term2 _Oppenheimer Strategic BondVA4 __%Fixed Account 10-Year Term2 _Pioneer Equity-Income VCT 4 Available in MD & WA _Pioneer Fund VCT Portfolio4 __%Guaranteed Interest Div(DCA Only) 100 % Total 1 In addition to management fees and other charges, many of the classes of funds being offered as investment options also have 12b-1 fees. 2 Not available in OR 3 DCA does not ensure a profit or guarantee against loss in a declining market. Not available with the GET Fund. 4 This portfolio's available share class is subject to service and/or 12b-1 fees. GA-CDF-1105 Page 2 of 4 01/15/2003 111541/M.P.MS.60 TELEPHONE REALLOCATION AUTHORIZATION (Owner's initials to validate agent) _________________ I authorize Golden American to act upon reallocation instructions given by electronic means or voice command from the agent that signs below and/or the following individuals: _____________________, ______________________; upon furnishing his/her social security number or alternative identification. Neither Golden American nor any person authorized by Golden American will be responsible for any claim loss, liability, or expenses in connection with reallocation instructions received by electronic means or voice command from such person if Golden American or other such person acted on such electronic means or voice command in good faith in reliance upon this authorization. Golden American 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 Golden American in writing of a change in instructions. 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. Arkansas, Colorado, Kentucky, Louisiana, New Mexico, Ohio, Oklahoma, Pennsylvania and Washington, DC: "Any person who knowingly and with intent to defraud any insurance company or any 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. California: For your protection, California law requires the following to appear on this form. "Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in a state prison." California Assembly Bill 2107 Disclosure: 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, stock, bond, IRA, certificate of deposit, mutual fund, life insurance policy, annuity contract or other asset. Florida: "Any person who knowingly and with the intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree." Maine, Tennessee: "It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits." Minnesota: This contract is not protected by the Minnesota Life and Health Insurance Guaranty Association or the Minnesota Guarantee Association. In the case of insolvency, payment of claim is not guaranteed. Only the assets of this insurer will be available to pay your claim. 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." Virginia: "A 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." ACCOUNT REBALANCING PROGRAM _ I elect the Account Rebalancing Program. (check one) _ Quarterly _ Semiannually _ Annually With this program, amounts in the variable investment options are reallocated, as frequently as you elect above, to reflect the percentages indicated on this form. May not use DCA concurrently. Account Rebalancing Program is not permitted into the GET Fund. SYSTEMATIC WITHDRAWAL OPTION Amount (per year): $______________ or ______________% (up to a maximum of 10% per account year) Frequency: _ Monthly _ Quarterly _ Annually Start date: ____________________ (mo/yr) on the _ 15th or _ 28th Electronically deposit my payments to: Account # ______________________ Bank Routing # ____________________________ (Please attach VOIDED check.) Federal law requires that 10% must be withheld from taxable distributions unless you elect not to have taxes withheld. You may be subject to tax penalties if your payments of estimated tax and withholding are not adequate. _ I do not wish to have taxes withheld GALIC offers other Systematic Distribution Options. Please refer to the Systematic Distribution Options form. SPECIAL REMARKS GA-CDF-1105 Page 3 of 4 01/15/2003 111541/M.P.MS.60 EXISTING COVERAGE Do you currently have any existing annuity or life insurance policies or coverage? _ Yes (If 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 the new policy or contract? Yes _ No _ If you answered "yes" to either of the above questions, please complete any state replacement forms, if applicable. I do not want this notice read aloud to me, ________(Owner/Applicant's must initial only if they do not want the notice read aloud.) DISCLOSURES AND SIGNATURES ____________ Please read the following statements carefully and sign below: By signing below, I acknowledge receipt of the current Prospectus. I agree that, to the best of my knowledge and belief, all statements and answers herein are complete and true and may be relied upon in determining whether to issue the contract. Only the owner and GALIC have the authority to modify this form. Contracts and policies and underlying Series shares or securities which fund contracts and policies 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. Also, they are subject to market fluctuation, investment risk and possible loss of principal invested. I understand that the contract's cash surrender value, when based on the investment experience of the Separate Account, may increase or decrease on any day and that no minimum value is guaranteed. The contract's coverage is in accord with my anticipated financial objectives. I understand that any amount allocated to the Fixed Account (MVA Account) may be subject to a Market Value Adjustment, which may cause the values to increase or decrease, prior to a specified date or dates as specified in the contract. (This account is not available in MD or WA.) My signature certifies, under penalty of perjury, that the taxpayer identification number provided is correct. 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. __________________________________________________________________________ Signature of Owner Signed at (City, State) Date __________________________________________________________________________ Signature of Joint Owner (If applicable) Signed at (City, State) Date __________________________________________________________________________ Signature of Annuitant (If other than owner) Signed at (City, State) Date FOR AGENT USE ONLY Do you have reason to believe that the contract applied for will replace any existing annuity or life insurance coverage? _ Yes (If yes, submit required replacement forms.) _ No _ A _ B _ C Client's Account Number: ___________________________________ __________________________________________________________________________ Agent Signature Print Agent Name Agent Phone Number __________________________________________________________________________ Social Security # License#/Broker -Code Broker/Dealer/Branch GA-CDF-1101 Page 4 of 4 01/15/2003 111541/M.P.MS.60